Real-life effectiveness of ICS/LABA inhalers in asthma: The evidence generated and future needs for optimal patient management

The fixed-dose combinations (FDC) of inhaled corticosteroids (ICS) with longacting β2-agonists (LABA) represent one of the most widely used controller options for the management of patients with asthma, worldwide. Recently, the Global Initiative for Asthma (GINA) reports recommended the use of ICScontaining regimens in all the steps of asthma management, suggesting that the preferred reliever option would be combinations of ICS/formoterol, setting consequently these inhalers as the preferred controller option for such patients1. In the quest of the selection of the appropriate inhaled medication for our patients with asthma, a broad choice of inhalers is currently available. The treating physician needs to take into consideration several characteristics of the inhalation device, involving both the substances included but also the characteristics of the device that will be most appropriate for the individual patient, in order to ensure the acceptability of the device by the patient that will consequently lead to better adherence to the inhaled treatment and better disease outcomes2. The ‘ideal’ inhaler should carry several properties, including being userand environmental-friendly (e.g. being breath-actuated, being multi-dose and portable yet robust, avoiding harmful additives, e.g. propellants), allowing for control of the appropriate dosing by providing feedback and dose receipt confirmation, providing the dosing independently of environmental conditions and inspiratory flow rate, and achieving high lung deposition with high respirable fine particle fraction3. In the journey of the management of patients with airways disease, the treating physicians should be familiar with the properties of the inhalation devices that they prescribe, choose the appropriate device based on the characteristics of each individual patient, involve actively the patients in the device and treatment selection, evaluate the patients’ inhalation technique and train them appropriately at each visit, and re-evaluate the need for a different device whenever they identify a potential gap in the use of the previous one, but switch to a new device only with the patients’ involvement and appropriate education4. The dry powder inhaler (DPI) combination of budesonide and formoterol in the Elpenhaler® has been shown to be bioequivalent in terms of lung deposition to the same formulation delivered by the Turbuhaler® device in a crossover pharmacokinetic study in 100 patients with asthma5. Moreover, there is evidence of high satisfaction and acceptability of the Elpenhaler® in patients with asthma and COPD using the Feeling of Satisfaction with Inhaler (FSI-10) questionnaire that was comparable or better to other DPI devices6,7, whereas it also presented lower rates of critical errors that affect drug delivery to the lungs when compared with the Diskus® and Turbuhaler® devices in a prospective study of 755 patients with asthma and COPD8. In this issue of Pneumon, Bakakos et al.9 provide further clinically relevant information on the real-life effectiveness of the ICS/LABA combination of budesonide/formoterol in the Elpenhaler® device in patients with asthma, by presenting the results of the BOREAS study. This is a 6-month prospective multicenter observational study that enrolled 1230 asthma patients who were prescribed either of the two doses of Elpenhaler® budesonide/ formoterol (200/6 or 400/12 μg). The authors were able to show significant AFFILIATION 1 Respiratory Medicine Department, Medical School, University of Ioannina, Ioannina, Greece 2 Respiratory Medicine Department, University Hospital of Ioannina, Ioannina, Greece 3 Respiratory Medicine, Observational and Pragmatic Research Institute, Singapore, Singapore