Triple Combination Therapy in Severe Asthma: Overview from the Italian Registry Severe Asthma (IRSA)

Introduction: The Global Initiative for Asthma recommend Tiotropium (TIO) Respimat add-on therapy for patients with uncontrolled severe asthma (SA) (step5). Randomized double blinded studies showed that Tiotropium-Respimat added to high dose Inhaled Cortico-Steroids (ICS)/ Long-Acting β2-Agonists (LABA) treatment significantly improved lung function thus extending the time to the first asthma exacerbation and reducing frequency. Aim: To assess the use of triple inhaler therapy in Allergy and Pulmonology Departments adhering to the Italian Registry of Severe Asthma (IRSA). Methods: We analysed 1218 patients enrolled in the IRSA. All patients provided written informed consent. Results: 1215 patients (477 male, 738 female) were included in the analysis. 41% patients were treated with ICS/LABA/TIO and 59% with ICS/LABA. Patients taking Triple therapy had a worse lung function (FEV1 67%±21 vs 75%±20; p<0.001), high number of exacerbation/year (3.9±4 vs 2.8±3; p>0.001) and were regularly treated with systemic steroids (37% vs 28%). However, they had reduced IgE levels (520±1475 vs 561±1194). In addition, 57% of ICS/LABA/TIO patients used biologics compared to 66% of LABA/ICS patients. Conclusions: To reduce exacerbations, LABA/LAMA/ICS are recommended in patients with uncontrolled SA. Moreover, the optimization of inhaler therapy is mandatory before starting biological treatment approach. IRSA network revealed a low percentage of patients treated with triple combination therapy also in those using biologics. Additionally, IRSA Centres used to prescribe triple therapy especially to patients with more SA and a non-allergic phenotype.