Clinical characteristics, treatment patterns and adherence in patients with asthma on multiple inhaler triple therapy: a review of findings

ABSTRACT

Introduction

The value of treating asthma with the triple regimen of inhaled corticosteroid (ICS), long-acting β₂-agonist (LABA), and long-acting muscarinic antagonist (LAMA) delivered using multiple inhalers (MITT), or a single inhaler (SITT) is supported by a growing body of evidence, although research is still limited regarding the use of MITT.

Areas covered

Clinical characteristics, treatment patterns, disease burden, and persistence/adherence associated with MITT use in asthma. The MEDLINE database was searched to identify references from inception until October 2022.

Expert opinion

The use of MITT is not very frequent in asthma patients, although it improves lung function and reduces the incidence of severe exacerbations. This may be due to existing concerns about using different devices on adherence and persistence to treatment, with a negative influence on outcomes, and to the fear that the patient will discontinue ICS/LABA but not LAMA. Nevertheless, although the current trend favors the SITT approach, some physicians may be induced to prescribe MITT over SITT because it allows the titration of individual components of triple therapy to be increased or decreased. Therefore, there is an evident need for pragmatic real-life studies to document when to prefer SITT and when MITT should be used.

KEYWORDS:

• Asthma
• triple therapy
• multiple inhalers
• single inhaler
• adherence
• persistence

Article highlights

• Positive pharmacological interactions between ICS, LABA, and LAMA during triple treatment result in considerable clinical advantages with an increase in lung function, an improvement in symptoms, and a decrease in exacerbation rates.

• LAMAs should always be added to an ICS/LABA maintenance therapy regimen as part of a MITT protocol or included in a SITT.

• The use of MITT is not very frequent in asthma patients mainly because LAMAs are little utilized.

• MITT users are predominantly female of mature age, frequently suffer from asthma-associated comorbidities, and often are recurrent exacerbators.

• The use of MITT in asthma is linked to low levels of adherence and persistence.

• Although the current trend favors the SITT approach, some physicians may be induced to prescribe MITT over SITT because it allows the titration of individual components of triple therapy to be increased or decreased.

• There is a clear need for pragmatic real-life studies to document when to prefer SITT and when MITT should be used.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript is on the advisory board or speaker’s bureau for AstraZeneca, Boehringer Ingelheim, Covis, Cipla, GSK, Merck, Novartis, Pfizer, Sanofi, Teva, Trudel, Valeo. Another reviewer on this manuscript has performed consulting, served on advisory boards, or received travel reimbursement from Amphastar, AstraZeneca, Chiesi, Connect Biopharma, GlaxoSmithKline, Mylan, Novartis, Sunovion and Theravance. They have also has conducted multicenter clinical research trials for some 40 pharmaceutical companies. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.