Association of inhaled corticosteroids and long-acting muscarinic antagonists with asthma control in patients with uncontrolled, persistent asthma: a systematic review and meta-analysis

Diana M Sobieraj, William L Baker, Elaine Nguyen, et al.
JAMA 2018;319(14):1473–84
doi: 10.1001/jama.2018.2757

Guidelines recommend the stepwise escalation of corticosteroid therapy when asthma severity increases, risking patient exposure to systemic effects of drugs and increasing the risk of adverse effects. Diana Sobieraj and colleagues explored the role of long-acting anti-muscarinics (LAMAs) as an adjunct therapy to inhaled corticosteroids (ICS) to aid the management of patients with persistent asthma. Data from 15 randomised clinical trials, covering 7,122 patients, was analysed, comparing the effect of add-on LAMA therapy on the risk of exacerbation with either a placebo or other controllers – e.g. long-acting beta₂-agonists (LABAs). Researchers also compared the effectiveness of triple therapy (LAMA, ICS and LABA) with ICS and LABA.

Results showed the addition of LAMA to ICS significantly reduced the risk of exacerbation when compared with placebo. However, when compared with other controllers (e.g. LABA), no significant improvement in asthma exacerbation risk was found. Triple therapy demonstrated some improved outcomes, but association with improved exacerbations was not demonstrated when compared with ICS and LABA therapy. Conclusions stated that, although use of LAMA does reduce the risk of exacerbation when compared with placebo, similar improvements were not noted when compared with other controllers or triple therapy. The researchers concluded that the association of LAMA with benefits to persistent asthma management may not be greater than that associated with LABA.