How would you treat a severe asthma patient?

Meet Your Patient

Asthma is a variable condition that requires a versatile treatment regimen – what treatment would you recommend for the following patient?

This patient case is fictional and created for educational purposes only.

Thomas, Age 40

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Thomas has lived with asthma since childhood but was recently diagnosed with severe asthma. He is currently treated with moderate-dose MART (maintenance and reliever therapy), but decides to visit his GP as his asthma symptoms are still interfering with his quality of life.

Current presentation	Hasn’t been sleeping well due to persistent coughing at night. Likes to stay active, but running triggers his asthma, so he has stopped recently.
Current treatment	Combination inhaled corticosteroid/long acting β2 agonist (800 mcg budesonide equivalent/day) used as MART.
Adherence	Good
Inhaler technique	Good
Eosinophil count	138 cells/mm³
FeNO	20 ppb
Severe exacerbation in the last 12 months	1 requiring oral corticosteroids.

SPIRIVA Respimat (tiotropium) is indicated as add-on maintenance bronchodilator treatment in patients aged 6 years and older with severe asthma who experienced one or more severe asthma exacerbations in the preceding year. In adult patients with severe asthma, tiotropium should be used in addition to inhaled corticosteroids (≥800 μg budesonide/day or equivalent) and at least one controller.¹

SPIRIVA Respimat (tiotropium) is the only single LAMA licensed for use as an add-on therapy in severe asthma.^1–9

The 2024 BTS, NICE, SIGN guidelines now recommend that people with asthma that is not controlled on moderate-dose MART, despite good adherence, can be trialled on a LAMA – such as SPIRIVA Respimat – in addition to MART in the primary care setting.¹⁰

The BTS, NICE, SIGN 2024 guidelines recommend that for people aged 12 and over whose asthma is not controlled on moderate-dose MART despite good adherence:¹⁰

Check the FeNO level if available, and the blood eosinophil count. If either of these is raised, refer to a specialist in asthma care.
If neither FeNO or eosinophil count is raised, consider a trial of either a LTRA or a LAMA used in addition to moderate-dose MART. Give the medicine for a trial period of 8–12 weeks unless there are side effects.

SPIRIVA Respimat (tiotropium) inhaler with cartridge and blue lid

SPIRIVA Respimat (tiotropium) is the only single LAMA licensed for use as an add-on therapy in severe asthma.^1–8

At the end of the trial:
- if asthma is controlled, continue the treatment
- if control has improved but is still inadequate, continue the treatment and start a trial of the other medicine (LTRA or LAMA)
- if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)
Refer to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART and trials of an LTRA and a LAMA.

For more information on the pharmacological management of asthma in people aged 12 years and older, please see the BTS, NICE, SIGN algorithm C, below.¹⁰

BTS, NICE, SIGN algorithm C

Why SPIRIVA Respimat (tiotropium)?

Learn more about the role of LAMA in severe asthma

BTS, NICE, SIGN algorithm C

Why SPIRIVA Respimat (tiotropium)?

Learn more about the role of LAMA in severe asthma

Abbreviations

BTS, British Thoracic Society; FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; NICE, National Institute for Health and Care Excellence; MART, maintenance and reliever therapy; SIGN, Scottish Intercollegiate Guidelines Network.

References

SPIRIVA Respimat (tiotropium) Summary of Product Characteristics.
SPIRIVA HandiHaler® (tiotropium) Summary of Product Characteristics.
Tiogiva® (tiotropium) Summary of Product Characteristics.
Braltus® Zonda® (tiotropium) Summary of Product Characteristics.
Incruse® Ellpita® (umeclidinium) Summary of Product Characteristics.
Seebri® Breezhaler® (glycopyrronium) Summary of Product Characteristics.
▼ Eklira® Genuair® (aclidinium) Summary of Product Characteristics.
Acopair® (tiotropium) Summary of Product Characteristics.
Trokide® (tiotropium) Summary of Product Characteristics.
BTS, NICE, SIGN. Asthma: diagnosis, monitoring and chronic asthma management. 2024. Available at: https://www.nice.org.uk/guidance/ng244 (accessed February 2025)

PC-GB-109486 V1 February 2025

Reporting adverse events

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 0800 328 1627 (freephone).

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