Triple Therapy for Asthma
Currently, it is confirmed that adults with underlying medical conditions such as heart failure and cancer are all at an increased risk of severe illness from the virus that causes COVID-19. However, according to the CDC, asthmatic, obese, pregnant, and immunocompromised adults might also be at an increased risk of having severe symptoms of the coronavirus. More than 25 million Americans have asthma, and it is one of the leading causes of hospitalizations in the United States. Nearly 65% of adults with current asthma have persistent asthma. People who have persistent asthma experience asthma symptoms daily and flare-ups can last for several days. Of those patients, between 5-10% of asthmatics experience symptoms that are difficult to treat despite taking multiple medications. For these patients especially, asthma can be life-threatening, making it all the more important to identify new ways to control asthma exacerbations and symptoms.
Asthma symptoms include shortness of breath, chest tightness or pain, wheezing, and coughing. These symptoms are all caused by airway inflammation and constriction. Thus, treatments are focused on relieving both processes. Inhalers is probably the most well known and popular treatment of asthma. They allow high doses of medication to reach the airway surfaces without significant absorption of medication into the bloodstream. Unfortunately, there are drawbacks to using inhalers. The first drawback is that patients must have meticulous technique when using their inhalers. Patients who are thought to properly use an inhaler often show significant improvements in symptom control (Kathleen). Another drawback is that inhalers that provide larger particles might not be as effective as inhalers that provide smaller particles. Particle size is a major determinant of which airways receive the medication. Larger particles are likely to be deposited in the mouth and upper airways while smaller particles are more likely able to make their way into smaller airways, which are more involved in asthma. Thus, inhalers that deliver smaller particles are more effective.
This is where triple therapy inhaler treatment comes into play. Triple Therapy involves combining an inhaled corticosteroid (ICS), a long acting beta 2 agonist (LABA), and a long-acting muscarinic antagonist (LAMA) into a single inhaler. According to The Lancet, combining three therapies into one inhaler improves lung function and reduces exacerbations in adults with uncontrolled asthma. The TRIMARAN study examined 1,155 patients from 16 countries who continued to have at least one asthma exacerbation a year despite extensive treatment. The TRIMARAN trial found that compared to the control group, the lung function in the triple therapy group had reduced moderate and severe exacerbations by 15%. In a similar fashion, the TRIGGER study also examined 1,437 patients from 17 countries who had severe asthma and also continued to have one exacerbation a year despite treatment. In the TRIGGER trial, it also had found that the rate of moderate and severe exacerbations were reduced by 12% in the triple therapy group. Sandrine Corre, the clinical project manager at Chiesi Farmaceutici, stated that since the preventive treatment delivered three drugs via one inhaler, and given the reduction in the annual rate of severe asthma attacks, it is expected that triple therapy would provide an attractive option to fulfill and unmet need for both individuals and health systems. Hence, the simultaneous use of all three medications would be more beneficial than using just corticosteroids.
Both the TRIMARIN and TRIGGER study help further our understanding on how to help patients who have hard to treat, persistent asthma. These studies also further suggest that adding long-acting muscarinic antagonists alongside inhaled corticosteroids and beta agonists help improve asthma control for patients. Additionally, the use of one inhaler containing all three classes of medications (steroid, long-acting beta agonist, and beta 2 antagonist) would be more convenient for patients to use rather than separating them into three inhalers. Especially during this pandemic, it is essential for asthmatics to continue to follow their Asthma Action Plan, and have at least a 30-day supply of medicine to prevent any increased risk for severe illness. Fortunately, the triple therapy for asthma appears to provide better treatment for severe asthma patients; hopefully after further testing, it would be reassuring to have better and more treatment options for these patients.
References:
https://www.jwatch.org/na50051/2019/10/22/triple-therapy-asthma-single-inhaler
https://www.health.harvard.edu/blog/triple-therapy-helps-control-severe-asthma-2020090220851
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html