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?

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...

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.

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

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 ref...