Switching from multiple-inhaler triple therapy to single, extra fine-inhaler triple therapy in severe refractory asthma with EGPA: beyond control. Case report and review of the literature

Abstract

Eosinophilic granulomatosis with polyangiitis is a rare systemic vasculitis associated with asthma, eosinophilia and multi-organ involvement. This case report describes a 69-year-old male with severe, poorly controlled asthma who was diagnosed with eosinophilic granulomatosis with polyangiitis. Despite treatment with mepolizumab 300 mg and optimized inhaled therapies, comprising high-dose inhaled corticosteroids and long-acting β2-agonists and a long-acting muscarinic antagonist in two separate inhalers, the patient exhibited poor asthma control, accompanied by exacerbations of symptoms, increased reliance on oral corticosteroids, and a decline in lung function. Consequently, a comprehensive, multidisciplinary approach targeting comorbidities was deemed necessary, including the management of chronic rhinosinusitis with nasal polyps. Following a switch to a single-inhaler triple therapy, the patient demonstrated significant improvements in terms of asthma control, respiratory function, oscillometric measurements and fractional exhaled nitric oxide reduction. This report underscores the significance of personalized treatment strategies and a treatable-traits approach targeting small airway dysfunction, persistent airflow limitation and type 2 inflammation for effective disease management. A literature review on therapeutic advancements and clinical implications is also presented to provide clinicians with useful insights into managing severe asthma and single-inhaler triple therapy placement.