Atualização do PCDT de Asma: Onde Fica o Papel do LAMA?

Abstract

Introduction (with objective): Asthma represents a significant public health problem in Brazil, with 33,375 deaths recorded between 2010 and 2024. Although the new Clinical Protocol and Therapeutic Guidelines (PCDT), updated in March 2026, provides essential immunobiological treatments and inhaled therapies, up to 45% of patients using inhaled corticosteroids combined with long-acting beta-agonists (ICS/LABA) remain without adequate clinical control (1). Although the Global Initiative for Asthma (GINA) points to the addition of long-acting muscarinic antagonists (LAMA) as an escalation option to optimize control before progression to biologics, the absence of this alternative in the PCDT may lead to the possible early use of immunobiologics, including in scenarios where clinical stabilization would be achieved through optimization of triple therapy (ICS/LABA/LAMA) (2,3). The objective of this study is to identify the gap related to the non-incorporation of LAMA in the asthma PCDT and to evaluate the role of extra-fine triple therapy (BDP/FF/G) as a possible therapeutic escalation strategy in patients who remain uncontrolled with ICS/LABA. Material and Method: Descriptive and comparative analysis between the current PCDT and the GINA recommendations, added to the analysis of scientific evidence on extra-fine triple therapy in the management of uncontrolled asthma. Results: GINA recommends the addition of LAMA in therapeutic escalation (steps 4 and 5), based on level A evidence that proves the reduction in the risk of exacerbations, especially in individuals with a history of exacerbations (2). In this scenario, the TRIMARAN randomized clinical trial demonstrated that the extra-fine triple therapy BDP/FF/G, the only one approved in Brazil for the treatment of asthma, reduces exacerbations by 15% and promotes improvement in pulmonary function compared to the ICS/LABA combination3. These findings are corroborated by the real-world TRIMAXIMIZE study, which associated the transition to BDP/FF/G with greater clinical control, improved adherence, and reduced need for rescue medication and systemic corticosteroids. Notably, approximately 40% of patients in this study achieved clinical remission (stability of pulmonary function, symptomatic control, absence of exacerbations and systemic corticosteroids), and the rate of migration to biologics during the study was low (4). Complementarily, a post-hoc analysis of the ATLANTIS study suggests that remission can be achieved in up to 50% of patients under optimized therapy, identifying small airway dysfunction as an independent predictor of response (5). This data reinforces the relevance of the extra-fine formulation of BDP/FF/G, whose greater peripheral deposition potentiates distal inflammatory control and the reduction of severe outcomes (3-5). Finally, systematic reviews indicate that escalation to high doses of ICS does not offer incremental clinical benefit compared to moderate doses, resulting only in increased adverse effects, which validates the strategy of adding LAMA instead of increasing corticosteroids alone. Conclusions: The data highlight a therapeutic gap between the PCDT and GINA. Extrafine triple therapy demonstrated a reduction in exacerbations, improved pulmonary function, and promotion of clinical remission. Its incorporation into the national protocol would represent an intermediate and cost-effective alternative, capable of postponing or mitigating early escalation to immunobiologicals in some cases, aligning national practice with current scientific evidence standards.