Addition of LAMA is beneficial in managing difficult asthma
M3 India Newsdesk May 03, 2022
Highlighted in this article are the benefits of triple therapy for asthma based on the Trimaran and the Trigger study.
Symptoms of asthma stem from a mixture of inflammation and constriction of the airway, so asthma therapies work on alleviating these mechanisms. Using inhalers, asthma drugs are administered through the airways. Without substantial absorption of drugs into the bloodstream, this method of delivery helps large doses to enter the airway surfaces.
Inhalers
There are several major disadvantages to inhalers. First, the patient must use proper and meticulous techniques while using it. Patients often experience significant improvement in symptoms after correct use.
Secondly, the particle size supplied by the inhaler plays a significant role in deciding which airways receive the device. In the mouth and large upper airways, larger particles are more likely to be deposited.
Smaller particles are more likely to find their way through the small airways, which are the ones most affected by asthma. As a result, inhalers that provide finer particles may provide more efficient control of asthma.
Understanding triple therapy
Two randomised trials, recently published in Lancet, contributed to our understanding of successful adult asthma therapies. These global trials were double-blind, randomised and well designed. These studies conducted over a period of 1 year gave enough time to see how the original responses were retained over time, and within the sample groups, to observe discrepancies in the incidence of asthma exacerbations.
The TRIMARAN study
- Studied >1100 patients from more than 15 countries with severe asthma exacerbations despite using moderate-dose inhaled corticosteroids.
- One group received inhaled corticosteroids and formoterol.
- Another group received inhaled corticosteroids, formoterol, and glycopyrronium long-acting muscarinic antagonist (LAMA) using a single inhaler capable of delivering smaller particles.
The TRIGGER study
- Studied >1400 patients from seventeen countries, with severe asthma exacerbations despite using high-dose inhaled corticosteroids.
- One group was treated with an inhaled corticosteroid and long-acting beta-agonist given in a single inhaler.
- The second group was treated with the combination corticosteroid and long-acting beta-agonist inhaler as well as tiotropium (a LAMA) using the second inhaler.
- The third group was treated with a combination of a corticosteroid, long-acting beta-agonist, and glycopyrronium using a single inhaler delivering small particles.
Observations
These two trials showed striking similarities in results. Patients who received the LAMA along with inhaled corticosteroid and long-acting beta-agonist had better lung function and lower exacerbations as opposed to the patients receiving only long-acting beta-agonist and an inhaled corticosteroid.
A longer time for the first exacerbation was also observed in both moderate and severe asthmatic patients. The changes with LAMA did not rely on the use of a specific inhaler for LAMA, which means that the good effects are actually attributed to adding LAMA and not because of the very small size of the particle.
What do we understand?
In our understanding of how to treat patients with asthma that is difficult to monitor, TRIMARAN and TRIGGER studies offer a move forward. These findings contribute to the current evidence of increased asthma regulation in patients with the most serious type of the condition by adding LAMA to inhaled corticosteroids and beta-agonists. An improvement in asthma treatment is the use of one inhaler containing all three types of drugs (steroid, long-acting beta-agonist, and LAMA).
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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.
The author is a practising super specialist from New Delhi.
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