Combination therapy for asthma: results of a Delphi process

Background. International guidelines recommend combination therapy with an inhaled corticosteroid (ICS) and a long-acting β₂-agonist (LABA) as part of a stepped approach to asthma management, but do not provide guidance on how to choose specific combinations. We report here the findings of an initiative undertaken under the auspices of the Global Allergy and Asthma European Network (GA²LEN) to reach agreement on which factors are the most important to consider when choosing an ICS/LABA combination for asthma.

Methods. A Delphi process was used to elicit three rounds of structured feedback from a panel of European respiratory experts from primary and secondary care who had a specialist research interest in the management of asthma. In round 1, panel members recommended factors to consider using free text. Responses were then coded and grouped for voting in round 2 using a 5-point anchored Likert scale (from 0 [not important] to 4 [very important]). The factors rated most important were included in statements circulated to the panel, who then voted their level of agreement in round 3. Consensus was defined a priori as ≥ 66% agreement.

Results. Thirty-two experts from 9 European countries (Austria, Finland, France, Germany, Italy, Spain, Sweden, Switzerland and the UK) were invited to participate; response rates were 59.4% in round 1, 84.2% in round 2 and 84.2% in round 3. Fifteen factors were identified through the free-text responses in round 1. Nine of these were rated as important or very important by ≥ 75% of the panel in round 2. In the final round, the panel reached consensus that the most important factors were: availability of a range of doses; clinical efficacy of the combination and long-term safety and tolerability of the components; speed of onset of the LABA and potency of the ICS.

Conclusion. In the absence of clear recommendations from international guidelines regarding the criteria that should inform the selection of an ICS/LABA combination therapy for asthma, the results of this Delphi process may help to guide the evaluation and assessment of these treatments.