The updated guidelines GINA and SATS now include addition of long-acting muscarinic antagonists (LAMAs) in steps 4 and 5.
One of the key messages of the latest version of the South African Thoracic Society (SATS) guideline is to incorporate the use of a LAMA in combination with inhaled corticosteroid long-acting beta2-agonist (ICS-LABA).
LAMAs are recommended as monotherapy for patients with moderate COPD. In asthma, when added to maintenance treatment with ICS alone or ICS/LABA, they improve lung function and may reduce the risk of exacerbations. Their effect on asthma symptoms is less consistent. They should be considered in patients who are uncontrolled on medium- to high-dose ICS-LABA.
There are currently no data to guide the clinician’s decision on whether to add a LAMA or ‘step up’ to a higher dose of ICS in a patient uncontrolled on medium ICS-LABA. Prescription of a LAMA should be considered in patients who are uncontrolled on high-dose ICS-LABA.
The Global Initiative for Asthma Strategy 2021 includes add-on LAMAs. Step 5 recommendations for add-on LAMA have been expanded to include combination ICS-LABA-LAMA, if asthma is persistently uncontrolled despite ICS-LABA.
• Add-on tiotropium in separate inhaler (ages ≥6 years)
• Triple combinations (ages ≥18 years): beclometasone-formoterol-glycopyrronium; fluticasone furoate-vilanterol-umeclidinium; mometasone-indacaterol-glycopyrronium.
Adding a LAMA to medium or high dose ICS-LABA modestly improves lung function but not symptoms. In some studies, an add-on LAMA modestly increased the time to severe exacerbation requiring oral corticosteroids. For patients with exacerbations, it is important to ensure that the patient receives sufficient ICS, ie at least medium dose ICS-LABA, before considering adding a LAMA.
Take-home messages from SATS guidance include:
• SA has one of the highest reported asthma mortality rates, despite availability of ICS in all sectors of the healthcare system
• Patients with so-called ‘mild’ asthma are at risk for acute exacerbations and death, and should have an ICS included in their management strategy
• Early diagnosis and control of asthma will reduce morbidity and mortality, and most people with asthma can lead a normal life with optimal control
• Long-term use of oral corticosteroids is strongly discouraged owing to their severe side-effect profile
• Inhaler technique and adherence must be addressed at every consultation before making any change in drug therapy. Poor technique is one of the most common causes of poor asthma control
• Lung function should be measured annually in patients with asthma to objectively measure lung function impairment. At each clinic visit, a simple and validated scoring method such as the Asthma Control Test (ACT) should be used to determine current asthma control
• Where possible, patient preference should be considered in the selection of inhaler device (dry powder or pressurised metered dose inhaler (pMDI)). Adequate instruction in inhaler technique is essential and should be checked at every visit
• Well-controlled asthma does not appear to be a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (Covid-19). Poor asthma control requiring the use of oral corticosteroids may increase the risk for Covid-19.