It is worth reading the recommendations prepared by a group of experts on the treatment of poorly controlled asthma using single-inhaler triple therapy (SITT) with a high dose of the inhaled corticosteroid. The management of asthma more severe than the moderate persistent disease has always raised numerous doubts. It has also been only moderately represented in both Polish and European guidelines.
In the STAN3T guidelines, we did not explore this area in greater depth because the availability of robust clinical trial data was relatively limited [1]. The situation was similar with regard to drug reimbursement in Poland.
In STAN4T, however, we succeeded in introducing a revolutionary recommendation to use triple therapy at a relatively early stage of asthma treatment [2]. We took a different approach than, for example, Global Initiative for Asthma (GINA), because we were well aware of clinical trials clearly demonstrating the potential to reduce exacerbations in patients treated with SITT – particularly in cases where inhaled corticosteroids (ICS)/long-acting β2-agonists (LABA) therapy did not provide a satisfactory number of asthma-controlled days for the patient [3–8]. In this way, we distinguished two therapeutic pathways for asthma management from step 3 onward:
treatment with medium or high doses of ICS/LABA in a single inhaler, or
the use of ICS/LABA/long-acting muscarinic antagonist (LAMA) triple therapy in a single inhaler.
We left the treatment decision to the physician. This was because the expert group concluded that asthma therapy is individualized by clinicians relatively early, and no guideline should limit a physician’s choice. GINA guidelines once took a similar approach, although it stopped at defining two treatment pathways. The STAN4T experts decided to enable patients to receive more effective therapy, better tailored to their clinical characteristics, practically throughout the entire course of asthma treatment. At that time, there were already good clinical studies supporting such recommendations. We did not, however, take a position on the ICS dose within triple therapy, as we considered this an unnecessary complication in guidelines intended for a broad group of physicians. The experts of Polish Society of Allergology (PTA) and Polish Respiratory Society (PTChP) address this issue in the position statement published below.
I continue to believe that triple therapy has many advantages. It appears particularly beneficial in patients with specific clinical features indicating insufficient asthma control despite ICS/LABA therapy, as I discussed in detail in an article published in 2025 [9]. Whether physicians choose to use this approach depends on their understanding of disease pathophysiology, clinical intuition, and familiarity with the evidence. Registration and reimbursement of triple-therapy medications also play an important role.
ICS/LABA combination therapy began to be used in Poland in the early 21st century. However, we had to wait more than 20 years for the widespread introduction of triple therapy.
Even now, just as 20 years ago, we still have a group of patients who do not achieve full asthma control despite using ICS/LABA at full, maximal doses.
For many years, LAMAs were medications reserved mainly for COPD or asthma–COPD overlap syndrome. Nevertheless, we have long known that their use was – and remains – particularly beneficial in asthma patients who exhibit certain clinical features:
persistent airflow obstruction,
progressive decline in ventilatory parameters despite adequate treatment,
frequent exacerbations,
chronic cough with substantial sputum production,
small airway dysfunction,
older age.
The discussion about whether these patients have severe asthma, difficult-to-treat asthma, or asthma–COPD overlap syndrome is largely academic. A practicing physician needs clear guidance on what to do. STAN4T has been providing such guidance for over a year. Unfortunately, the experts developing the GINA 2026 standards did not follow our example. Fortunately, in Poland, the STAN4T recommendations are legally binding. They are intended for family physicians, pediatricians, allergists, pulmonologists, and pediatric pulmonologists. Representatives of four Polish medical scientific societies and all the aforementioned specialties participated in their development.
I believe that the expert position on SITT, which you can now read, is a valuable complement to the concise and coherent STAN4T standards. I hope that both this document and my previously published review article on the place and role of triple therapy in asthma will help you manage your patients more effectively.
Triple therapy may be a very attractive therapeutic option before a patient proceeds to biological treatment [10]. It also reduces systemic treatment costs. Moreover, single-inhaler triple therapy provides asthma control comparable to that achieved with biologic therapy.
A practical approach to escalating asthma treatment in adults (from step 3 onward) – based on STAN4T and the PTA/PTChP Expert Position
Key conclusions
Lack of asthma control despite correct use of ICS/LABA → first consider escalation to triple therapy (SITT).
At step 4B → SITT (with a medium ICS dose) is the preferred option for treatment intensification.
At step 5 → SITT with a high ICS dose should be considered for most patients before qualification for biologic therapy.
Presence of clinical features such as:
Lack of control despite optimal inhaled therapy (including SITT) → consider qualification for biologic treatment.
Good asthma control maintained for ≥ 3 months → allows gradual treatment reduction (de-escalation)
Asthma treatment should be dynamic – escalation and de-escalation depend on current disease control, and the choice of the treatment pathway should be tailored to the patient’s clinical profile.
