Optimizing the Use of Inhaled Corticosteroid/Long-Acting β2-Agonist Combinations in Patients with Moderate-to-Severe Asthma

Current clinical recommendations for asthma management are based on a symptom-driven, stepwise approach; however, the effects of patient characteristics and patient preference should be considered as they can influence adherence and, in turn, treatment effectiveness. In this Practical Approach article, an international group of asthma specialists reviews the current evidence to be considered when prescribing (as initial or secondary therapy) conventional maintenance inhaled corticosteroid (ICS)/long-acting β₂-agonist (LABA), plus as-needed short-acting β₂-agonist (SABA), or maintenance and reliever therapy (MART) with ICS, and the LABA formoterol (FOR), to patients on the 2025 Global Initiative for Asthma (GINA) treatment steps 3 and 4 with moderate-to-severe asthma. Many of the trials evaluating MART performed during the last 2 decades have explored MART, and the results have influenced the current recommendations proposed by 2025 GINA and others; however, the 'conventional' strategy relying on maintenance ICS/LABA therapy plus as-needed SABA may be more suitable to some patients and easier to manage for some healthcare professionals (HCPs). The purpose of this article is to provide a practical approach to help HCPs choose the best management regimen for each patient, to facilitate a personalised strategy tailored to the individual patient characteristics rather than a uniform approach. A special focus is placed on circumstances where a conventional ICS (± LABA) + SABA strategy should be followed. The focus of asthma management should not be on asthma control alone, but should also consider the risk of long-term outcomes, particularly future exacerbation risk. In addition to real-world effectiveness, baseline characteristics and behavioural patterns, such as patient preferences and adherence patterns, need to be considered when choosing between conventional dosing with maintenance ICS/LABA plus as-needed SABA or MART.