The Woolcock Institute of Medical Research

You may have heard about triple therapy for the treatment of asthma. But what is triple therapy? And how do you know if it's right for you? 

We asked the Woolcock's Professor Sinthia Bosnic-Anticevich, a world-leading expert in asthma and respiratory conditions, to explain about triple therapy.

What is triple therapy?

When we talk about ‘triple therapy’ for asthma, we are referring to inhalers that contain three different medications. The three medications are an anti-inflammatory (inhaled corticosteroid) and two long-acting bronchodilator medications (medications that result in opening of the airways).

Most people with asthma are familiar with ‘dual therapy’, which is one inhaler with two different medications (an anti-inflammatory and a long-acting bronchodilator), which have been available for the treatment of asthma for many years now.  Triple therapy adds an extra bronchodilator.

While triple therapy has been available for people with chronic obstructive pulmonary disease (COPD) for a while, it's just in the last few months that it’s become available for people with asthma too. So triple therapy is an exciting new treatment option for people with asthma.

Clinical trials show that triple therapy is superior to dual therapy in patients whose asthma is poorly controlled at moderate to high doses of medication. It’s a really important addition to the suite of medications we use to treat asthma. 

Note: It’s important to know that there are two types of dual therapy: dual therapy that contains a corticosteroid plus a bronchodilator (used in asthma); and dual therapy that contains two bronchodilators (used in COPD).

Who is triple therapy for? 

To answer that, it's important to understand the fundamental principles by which we currently manage asthma. We use what is known as a ‘stepwise’ approach. That means we start patients on the lowest possible dose of inhaled medications, then monitor and review to see how they are going on that treatment.

At follow up, if patient adherence and inhaler technique are good, but the patient is still experiencing asthma symptoms, we increase – or ‘step up’ – their dose of inhaled medication. 

This process of review and medication adjustment is common and continues until good asthma symptom control is achieved and maintained.

For some patients, moderate to high doses of dual inhaler therapy may simply not be enough to control their symptoms. Previously, the only option for this group of patients was to further step up therapy to either oral corticosteroids or biological therapy (biologics are injections, which can only be initiated by respiratory specialists and is reserved for severe asthma).

Triple therapy offers an alternative: patients who do not have sustained good asthma control on moderate to high doses of dual inhaler therapy can now be stepped up to triple therapy. 

This new option has several possible advantages:

• patients can seamlessly transition to triple therapy simply by changing their inhaler (in some cases they can even use the same type of inhaler with the additional bronchodilator);
• inhaler medications, if used correctly, have minimal side effects compared with oral corticosteroids; and
• inhaled medications are perhaps more convenient to use compared with biological therapy, which requires a healthcare provider to administer an injection.

If I have asthma, how do I know if triple therapy is right for me?

This is not an easy question to answer, because we know through our research and real-life experience that when we review the effectiveness of a patient’s therapy, a lot of people are not using their current preventer medication properly. Either they aren’t using it regularly, or their inhaler technique is suboptimal – both of which can impact on the effectiveness of their medication.

So, to go back to the question, in theory, a patient who might be a candidate for triple therapy is one who is on moderate to high doses of inhaled preventer medication, but is still experiencing symptoms, having flare ups and needing to use their reliever regularly, say more than twice a week.

If you fit this description, you really need to get your adherence and inhaler technique assessed first. Only once your doctor is confident you’re adhering properly to your preventer medication and have good inhaler technique, will it be possible to determine whether you are a candidate for triple therapy.

If I’m interested in finding out more about triple therapy for my asthma, what should I do?

Go and see your doctor or your pharmacist and ask them about triple therapy.

But first, it's really important to make sure you're using your current inhaler medication properly.

I suggest you take a two-week challenge: say to yourself, okay, for two weeks, I'm going to really try and use my inhaler medication regularly, and I'm going to monitor how I feel. Over those two weeks, try to use your inhaler exactly as advised.

Two weeks isn't long enough to get maximum benefit from inhaled medications; three to four weeks may give a better idea. But two weeks is easy to commit to and is enough time for you to start to see whether your medication is really working or not. 

Our whole mantra is to get good disease outcomes with the lowest dose of medication possible. We don't want to put people on higher doses, or more medications, unless it’s absolutely necessary.

So if you’re considering whether triple therapy may be right for you, first do a proper, honest review of your current inhaler medication with the help of your GP or pharmacist. You may even find you are able to step down your medications, rather than step up to triple therapy.

Find out more

• Are you using your inhaler correctly?, in which Sinthia talks about the importance of reviewing and refining your inhaler technique.
• When less is more: why doctors might consider stepping down patients’ asthma medication
• About respiratory services at the Woolcock Clinic