LAMA and ICS in moderate asthma

Paul M. O’Byrne, MB, is a professor of medicine and dean and vice-president of the Faculty of Health Sciences at McMaster University.

Is it possible to use a long-acting muscarinic antagonist (LAMA) with an inhaled corticosteroid (ICS) instead of a long-acting beta₂-agonist (LABA) and ICS in patients with asthma requiring GINA step 3 treatment?

The use of a long-acting muscarinic antagonist (LAMA) in asthma has been confined to patients with a more difficult to manage asthma, with Global Initiative for Asthma (GINA) step 4 and 5, added on to a combination of inhaled steroids and inhaled long-acting beta₂-agonists (LABAs). The evidence for that is that there is a small but clinically useful reduction in exacerbation risk when the LAMA is added.

What we don’t know is whether there is any benefit in using a LAMA only with an inhaled steroid compared to a LABA only with an inhaled steroid. Those studies have not been conducted and so at the moment we don’t have any evidence to be able to recommend that treatment approach.