Written by Mary Marschner
Spoon Feed
In an adult with uncontrolled asthma on an inhaled steroid, adding tiotropium is superior to doubling the dose of inhaled steroid, and noninferior to adding inhaled long acting beta agonist.
No drama, just add a LAMA
Incidence of asthma has continued to increase, and it is very important to review current guidelines for treating asthma to minimize exacerbations and daily symptoms for our patients. Currently, we use the step-up approach to treatment. Every patient will need a rescue short-acting beta agonist (SABA) inhaler. Next is a daily low-dose steroid plus a PRN SABA. Once this is no longer controlling symptoms, the recommendations are an inhaled corticosteroid with a long-acting beta agonist (LABA) or a long-acting muscarinic antagonist (LAMA). This study shows adding a LAMA or a LABA is better than doubling the dose of corticosteroid. It shows noninferiority of a LAMA to LABA; LAMA showed greater symptom relief that did not reach statistical significance. The study evaluated tiotropium bromide (LAMA) as a step-up therapy for adults with uncontrolled asthma. This randomized, double-blind, placebo-controlled trial involved 210 patients. Tiotropium significantly improved lung function (FEV1) and asthma control compared to placebo, with a mean difference in FEV1 of 0.14 liters (p<0.001). This was an ideal study design and was limited mainly by follow-up duration and number of patients. Without a longer study, they were unable to comment on any long-term complications of being on a LAMA.
How does this change my practice?
This is a great example of well-executed study design for the treatment of asthma. It changed both my practice and American College of Chest Physicians (CHEST) recommendation to start a LAMA after initiating inhaled corticosteroid.
Source
Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010 Oct 28;363(18):1715-26. doi: 10.1056/NEJMoa1008770. Epub 2010 Sep 19. PMID: 20979471
