Use of long-acting muscarinic antagonists for severe asthma: insights from clinicians in the SHARP network

There is limited real-world evidence on the use and positioning of inhaled long-acting muscarinic antagonists (LAMAs) for treating severe asthma.

We aimed to assess the differences in clinicians' perspectives on prescribing LAMA for severe asthma across Europe.

Within the Severe Heterogeneous Asthma Research collaboration, Patient-centred (SHARP) network, we conducted a multi-country survey of 470 respiratory clinicians in 2023-24.

Most participants were pneumonologists (83%). 68% reported using specific criteria for prescribing LAMA for severe asthma, primarily fixed bronchial obstruction (68%), frequent asthma exacerbations (65%), and a history of smoking (53%). Improved quality of life, lung function improvement, and reduction of asthma exacerbations were the three expected outcomes of LAMA treatment that showed the largest agreement across clinicians (85-95%). As compared to non-severe asthma specialists (about 50% of the sample), severe asthma specialists were more likely to report always prescribing LAMA before biologics (54 vs. 41%) and before oral corticosteroids (OCS) (51 vs. 40%). Approximately 90% of participants prioritised tapering or discontinuing OCS before stopping LAMA. Overall, participants in Northern (n = 73) and Western Europe (n = 71) appeared less prone to prescribe LAMA and less confident in their benefits compared to those from Eastern (n = 88) and Southern Europe (n = 238). In particular, most participants from Latvia (91%) and Lithuania (67%) reported that LAMAs are not reimbursed for severe asthma in their countries. Most participants who expressed their opinion favoured triple therapy (n = 236) over single inhaler therapy (n = 91).

Our findings show that barriers and heterogeneous approaches still limit LAMA prescription for severe asthma in Europe, potentially leading to the underuse of this treatment option. Establishing a clear role for LAMA within a precision medicine framework is crucial; this aspect is not yet firmly supported by current international recommendations.