Inhaled Corticosteroid/Long-Acting β2-Agonist Selection for Patients with Moderate-to-Severe Asthma: Considerations for Real-World Practice, A Narrative Review

The current standard of maintenance care for patients with moderate-to-severe asthma is the use of inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) medications; some patients may also require additional therapies including long-acting muscarinic antagonists or biologics to establish disease control. Presently, there is a striking discrepancy between the positive outcomes reported in randomised clinical trials (RCTs) of these therapies and real-world outcomes that may be independent of treatment adherence. Patients with asthma included in RCTs are selected using stringent eligibility criteria, for example they have never been heavy smokers. Because current recommendations rely on results from such exclusive RCTs, this calls into question the extent to which these recommendations are applicable in daily practice. Therefore, generalising information from RCTs can be a difficult task for a number of reasons, including differences between ICS/LABAs, varied responses to medications among patients and the limited time busy general practitioners have to bridge the care gaps that exist. Factors in choosing a desirable ICS/LABA may include (a) considerations in clinical decision-making; (b) differences in pharmacokinetic and pharmacodynamic properties of ICS/LABA molecules, therapeutic index; (c) individual patient factors which may influence or facilitate successful adherence to treatment; (d) ease of inhaler use; (e) underlying inflammation; and (f) balancing efficacy and long-term safety, including adverse events and long-term exacerbation risk, based on data from both RCTs and real-world evidence. This review article discusses factors that healthcare professionals may utilise when selecting an ICS/LABA treatment for their patients, by considering data from RCTs and real-world evidence in addition to geographical/environmental, personal, and disease factors, which may also influence the decision process, such as availability and affordability.