In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?

I have done both. Once I need to go to high-dose ICS/LABA or ICS/LABA/LAMA, I start looking at options for biologics. I work exclusively with children, so it depends on the age of the child and what is approved for their age. It is easier to add a LAMA under age than a biologic.

Assuming adherence to ICS/LABA, I would use high-dose ICS/LABA if FENO is high, especially if they have exacerbations. I would add Triple Rx in patients with low FENO, especially in the presence of obstruction on spirometry.

From the way the question is phrased, being a "candidate for biological" would mean (at least in my mind) poor control (ACT 15 or less) with current ICS/LABA dosing. There are a couple of ways to pursue this, depending upon patient specifics (assessment of DPI vs MDI inhaler technique, review of refill records to make certain the currently prescribed dosing regimen is being followed, and demographic characteristics). Assuming we have optimized the MDI inhaler technique, I would try to move to SMART therapy with either high-dose Symbicort or Dulera, depending upon insurance (in my experience, they are equivalent in effectiveness for SMART therapy), for a minimum three-month trial. We specifically reach out for approval to insurers when we pr...

Need to know the triggers for the asthma and any other comorbidities first.

Similarly to Dr. @Dr. First Last, I usually trial them on ICS/LABA/LAMA if possible, rather than high dose ICS/LABA with the anticipation that biologic may be added next. My preference is for ICS/LABA/LAMA over high-dose ICS/LABA, but unfortunately, I have been running into insurance coverage issues for ICS/LABA/LAMA, leaving me stuck with high-dose ICS/LABA prior to biologics for many of my patients. I only treat adult patients, though.

This is my strategy. Patients with severe allergic TH2 HIGH uncontrolled asthma with allergies, high IgE, and eosinophilia despite medium dose ICS LABA, I switch to high dose ICS LABA and LAMA simultaneously, and if they fail this a biological. IF they respond to, consider stepdown to medium dose ICS LAMA LABA. For patients with non-allergic, TH2 low that will respond less well to high dose ICS, in general, try LAMA LABA medium dose ICS first, and if they fail, then consider a biologic that works on the epithelial alarmin TSLP.