As triple therapy of inhaled corticosteroids (ICS), long-acting β-agonists (LABA), and long-acting muscarinic antagonists (LAMA) becomes widely available for patients with severe asthma, clinicians are attempting to understand the best implementation of these strategies, especially given the rapidly evolving biologics landscape.

“One, do all patients need to go on this combination of medications before getting to an asthma biologic? And two, while a patient is on an asthma biologic, what should we do with the background maintenance therapy that they are on?” asked Arjun Mohan, MD, Associate Clinical Professor at the University of Michigan and Associate Director of the Michigan Medicine Asthma Program.

Dr. Mohan will chair a session, Biologics and Maintenance Therapy in Severe Asthma: A Pro-Con Debate, exploring the decision-making process around those two topics, Wednesday, October 9, at 3:30 pm ET, in Room 206AB of the Boston Convention & Exhibition Center. 

In the first half of the debate, Dr. Mohan and Farrukh Abbas, MD, FCCP, Assistant Professor at the VCU School of Medicine and Director of the VCU Severe Asthma Clinic, will weigh the pros and cons of having all patients with severe asthma go through triple inhaler therapy before using biologics.

The current Global Initiative for Asthma recommends considering high-dose ICS in combination with a LABA (ICS-LABA) and/or the addition of LAMA in a separate inhaler or a single combination (triple) inhaler at step five for patients with uncontrolled asthma. 

“There is concern about the side effects of high doses of ICS-LABA, and there is evidence that LAMA addition may not consistently improve quality of life or symptom improvement. Also, we have conflicting data available related to LAMA efficacy in type 2 high vs type 2 low phenotypes,” Dr. Abbas said. “The available data will be discussed to help identify the best next step (biologic vs high-dose ICS-LABA vs addition of LAMA) when [asthma symptoms] remain uncontrolled on medium-dose ICS-LABA combination.” 

In the second half of the debate, Frédéric F. Little, MD, Clinical Associate Professor at the Boston University School of Medicine, and Garbo Mak, MD, Clinical Assistant Professor at the University of Washington School of Medicine, will discuss whether to taper background maintenance therapy while on biologics.

“One of the main arguments for tapering, and maybe tapering more aggressively, is that there are long-term risks of inhaled corticosteroids as well as other medicines used for maintenance therapy,” Dr. Little said. “I would advocate for waiting for a longer time period—four to six months of good control, no exacerbations, [and] improved asthma quality of life—before I would consider taking the chance that if I tapered too quickly, they could have an exacerbation requiring systemic corticosteroids.”