Multiple-inhaler Triple Therapy for Asthma in Adults Comes with High Risk of Discontinuation

Discontinuation of multiple-inhaler triple therapy may be common, but re-initiation is not uncommon, a study finds.

Discontinuation of multiple-inhaler triple therapy (MITT) for asthma was high among patients newly initiating treatment, according to study findings presented recently at CHEST 2021, the annual meeting of the American College of Chest Physicians. In fact, more than three-quarters of adults who began MITT had stopped using it at 6 months. The study also found, however, that approximately one-third of patients who had discontinued the therapy had reinitiated use 6 months later.

As context for their research the authors point to a limited amount of real-world data on patterns of treatment for asthma after discontinuation.

Data for the retrospective, observational cohort study were drawn from the Truven MarketScan administrative claims database and included adult patients with asthma who either initiated MITT for the first time (cohort 1) or discontinued MITT for the first time (cohort 2) between January 2017 and March 2019. Patients were excluded for absence of adequate baseline/follow-up data and for evidence of COPD or other respiratory conditions.

MITT initiation was defined as ≥1d of overlapping pharmacy claims for ICS-LABA and LAMA and discontinuation as a gap of >45d in overlapping days' supply of ICS-LABA and LAMA.

All patients were followed for 6 months for either discontinuation or reinitiation.

In cohort 1, there were 4132 adults with asthma who initiated MITT for the first time (mean age, 49 years; 67.9% women) and in cohort 2, 4393 who discontinued MITT for the first time (mean age, 50 years; 68.4% women).

The investigators found that after 6 months, 78% of those in cohort 1 had discontinued ≥1 medication in the 3-component treatment and only 22% used MITT continuously. In cohort 2, more than two-thirds (65.7%) of those who discontinued MITT had not resumed therapy at 6 months and 34.3% did reinitiate.

Among patients who discontinued triple therapy compared with those who continued there were more reports of asthma symptoms, including cough (53% vs 47.4%), wheezing (14.9% vs 12.7%) and chest tightness (22.5% vs 20.3%).

In an analysis of a proxy for uncontrolled symptomatic asthma, the study authors report that fewer patients who discontinued MITT reported ≥6 short-acting ß-agonist claims during their baseline year compared with patients who continued the triple therapy regimen (12.5% vs. 16%; P= 0.006). Also, among those who discontinued triple therapy, 72% used a combination of once- and twice-daily ICS/LAMA/LABA vs 64% of patients who continued MITT.

There were no significant differences observed between those who continued and those who discontinued MITT in demographics or comorbidities, nor did authors report any differences in history of asthma exacerbations at baseline between the groups.

When they compared the one-third of patients in cohort 2 who had reinitiated MITT with those in that cohort who had not, the authors report finding no differences in demographics.

During a presentation at CHEST 2021, Shiyuan Zhang said of the results: “Multiple-inhaled triple therapy dosing regimen and the complexity of that at initiation seemed to be an independent predictor of discontinuation by 6 months, with once-daily ICS/LABA plus once-daily LAMA regimen associated with a 19% lower risk of discontinuation than the more complex regimens.”

Reference: Meeraus W, Liu Y, Numbere B, et al. Zhang WS, et al. Discontinuation and re-initiation of multiple inhaler triple therapy in adult patients with asthma: a cohort study. Chest. 2021;doi:10.1016/j.chest.2021.07.1737.