Treatment of asthma: roles of different classes of drugs Dr. Paul O'Byrne in an interview with Dr. Roman Jaeschke: part 1.

POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2016; 126 (12) The information we now have about asthma management, asthma control, and particularly the more acute severe events, exacerbations, hos‐ pital admissions, and so forth, is actually very en‐ couraging. In Ontario, where I work, the risk, for example, of children being admitted to an emer‐ gency room and into a hospital setting for acute severe asthma is reduced by half compared to 10 years ago. That is a very dramatic change, and it is because of the—in my view—almost certain‐ ly increased use of ICSs, at low doses; we do not need high doses to manage most patients. I think it is widely accepted now that with in‐ haled steroids as a monotherapy or ICSs together with a long ‐acting ß2 ‐agonist (LABA) in the same device, we can manage really well, probably 90% of patients with asthma or even more. The chal‐ lenging piece is getting the patient to use the med‐ ications regularly, particularly when they are feel‐ ing well. That is another topic for discussion. We do, however, have a subset of patients who are on optimal inhaled therapies with ICS/LABA at the optimal doses or highest doses in whom asth‐ ma is not well controlled. The treatment recom‐ mendations are now indicating that we should, as the next step, add a long ‐acting muscarinic antag‐ onist (LAMA), to the combination of ICS/LABA. That is because of 2 large studies, published again in the New England Journal of Medicine a couple of years ago, showing that adding a LAMA in that clinical setting does 2 things: it improves lung function and it further reduces severe exacer‐ bation rates. The evidence is very compelling, and now that approach is approved in Canada and many other countries as a third ‐line thera‐ py for patients. However, even with adding the LAMA, we are still left with a subset of patients in whom you have assured that adherence is adequate or done your best to do that, tried to rule out other co‐ morbidities that can make asthma worse, like rh‐ inosinusitis, gastroesophageal reflux, and so on, and you are left with people who have what is now called severe refractory asthma. And it turns out that about 60% of these patients have a persisting In a previous interview,1,2 you talked about the history of asthma, use of inhaled corticosteroids (ICSs), and use of shortand long -acting ß2 -agonists. Specifically, in part 2 of the interview,2 you mentioned the use of muscarinic antagonists, both shortand long -acting, and I wonder if we could now reflect on something different which is the place of different drugs in management of asthma, including those muscarinic antagonists. CLINICAL PRACTICE INTERVIEWS