Appropriate Use of Single Inhaled Triple Therapy in Uncontrolled Asthma: A Multinational Modified Delphi Consensus

Uncontrolled asthma is associated with impaired lung function, higher frequency of severe exacerbations, reduced quality of life, and increased healthcare costs. Although inhaled corticosteroids with long-acting β2-agonists (ICS/LABA) form the cornerstone of treatment, many patients continue to experience suboptimal disease control. Despite additional therapeutic strategies, their utilization is inconsistent. We conducted a modified Delphi consensus among expert clinicians to understand their perceptions of treatment strategies in uncontrolled asthma and evaluate their approaches beyond ICS/LABA therapy with a focus on single-inhaler triple therapy and other add-on options, including biologics.

The study consisted of two rounds of online surveys and a panel meeting involving 27 respiratory experts from nine countries. A 59-statement questionnaire (52 consensus statements, seven open) was developed following a literature review. Responses were recorded using a 9-point scale ranging from 1 (disagreement) to 9 (agreement) with a consensus threshold of 75%.

All experts participated in both surveys, and 22/27 attended a virtual panelists' meeting. Consensus was reached on 39/52 and 3/13 statements in surveys-1 and -2, respectively. Most panelists (15/27) estimated that 26-50% of their patients with asthma have uncontrolled disease. Improvement in symptoms and reduction in exacerbations were perceived as key indicators of asthma control (96% agreement). Additionally, 93% agreed that adding a long-acting muscarinic antagonist (LAMA) to medium-high dose ICS/LABA is a valid option for patients with uncontrolled asthma, citing benefits in symptom relief, lung function, and exacerbation reduction. Consensus was not reached on the use of azithromycin, leukotriene modifiers or biologics in this population.

In this modified Delphi consensus, international respiratory experts agreed on adding LAMA in patients who remain uncontrolled on medium-high dose ICS/LABA. Most consensus statements aligned with prevalent guidelines. However, divergent opinions on the use of azithromycin, leukotriene modifiers or biologics highlight the need for evidence-informed treatment decisions.