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Should maintenance on long-acting beta agonist/inhaled corticosteroid be revisited?

Published online: January 22, 2020

Asthma guidelines recommend step-down from inhaled corticosteroid/long-acting beta agonist (ICS/LABA) combination therapy to inhaled corticosteroid (ICS) monotherapy once asthma control has been achieved. In a recently reported 26-week study (referred to as Safety Pharma Investigation of Respiratory Outcomes (SPIRO)), comprising 11,729 patients ≥ 12 years of age with asthma who had previously been treated with ICS/LABA, ICS or other asthma medications, use of mometasone furoate/formoterol (MF/F, an ICS/LABA) did not pose a significantly greater risk of serious asthma-related events compared to mometasone furoate alone (MF, an ICS), and decreased the risk of asthma exacerbation. Therefore, the authors questioned whether patients whose asthma is clinically stable on an ICS/LABA combination, such as MF/F, should continue this therapy or be stepped down to ICS monotherapy, such as MF alone.

To better understand this question, Weinstein and colleagues used data from 8,447 patients with clinically stable asthma in the SPIRO trial who had been receiving the same dose of ICS/LABA for ≥ 4 weeks prior to study entry. The results of this study were recently published in The Journal of Allergy & Clinical Immunology: In Practice. The main goal of the study was to evaluate the risk of serious asthma-related events (hospitalization, intubation, and death) and asthma exacerbation (defined as hospitalizations ≥ 24 h, emergency visits < 24 h requiring systemic corticosteroid, and systemic corticosteroid for ≥ 3 consecutive days) in patients who remained on ICS/LABA (MF/F) or stepped-down to ICS (MF) for up to 26 weeks.

The results showed that there was no significant difference in the risk of asthma-related hospitalization (no asthma-related intubations or deaths occurred) among patients maintained on ICS/LABA with MF/F compared to those who stepped down from ICS/LABA to MF. In contrast, the risk of asthma exacerbation was significantly lower in patients maintained on ICS/LABA with MF/F compared to those who stepped down from ICS/LABA to MF. The authors concluded that maintenance on ICS/LABA combination therapy with MF/F reduces the risk of asthma exacerbation compared with LABA step-down to MF alone, without changing the safety profile. These additional findings add to our knowledge about risk/benefit of these therapies in the treatment of persistent asthma and may further assist prescribers when making treatment decisions, particularly in patients who are being considered for step-down from ICS/LABA to ICS.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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