Results from a UK consensus about the optimal prescribing of medium strength triple therapy in uncontrolled adult asthma patients in the NHS.

Abstract

Context: An inhaled corticosteroid (ICS) in combination with a long-acting β2-agonist (LABA) is a common treatment approach for asthma patients not controlled on ICS alone, but a significant proportion of patients remain uncontrolled on this combination and treatment adherence can also be a challenge. One of the options for adults whose asthma is uncontrolled in an ICS/LABA is the addition of a long-acting muscarinic receptor antagonist (LAMA), an approach commonly referred to as 'triple therapy'. The use of medium-strength ICS/LABA/LAMA is established in treating chronic obstructive pulmonary disease but is less well-established in asthma. Lack of clarity exists regarding who should prescribe ICS/LABA/LAMA and in which patients, and this is compounded by a lack of consistency among guidelines.

Aims: To define the optimal prescribing of medium-strength ICS/LABA/LAMA triple therapy in adult asthma patients uncontrolled on ICS/LABA.

Methods and material: Using a modified Delphi method, a panel of experts developed 39 Likert scale statements across six key domains. These statements were used to develop an online survey that was distributed to healthcare providers (HCPs) working with adult asthma throughout the UK. The threshold for consensus was set at 75%.

Results: In total, 314 responses were received from primary and secondary care stakeholders involved in the management of asthma. On analysis, 22/39 statements reached a very strong agreement (≥90%) and 16/39 attained strong agreement (≥75% and < 90). From these results, the panellists developed a set of twelve recommendations to help define how an optimal approach for prescribing triple therapy in patients who are uncontrolled on an ICS/LABA can be achieved.

Conclusions: The strength of agreement shows that HCPs support the use of medium-strength ICS/LABA/LAMA triple therapy in appropriate asthma patients, and that clarity is needed regarding how best this can be achieved. The proposed set of recommendations provides such guidance to support the prescribing of triple therapy in primary care.