What alternative asthma treatment without corticosteroids can be used for a patient on Trelegy with increased intraocular pressure?

Alternative Asthma Treatment for Patients with Increased Intraocular Pressure

For a patient with asthma currently on Trelegy who has developed increased eye pressure, leukotriene receptor antagonists (LTRAs) such as montelukast are the most appropriate non-steroid alternative treatment option.

Understanding the Problem

Trelegy is a triple therapy inhaler containing:

• An inhaled corticosteroid (ICS)
• A long-acting beta-agonist (LABA)
• A long-acting muscarinic antagonist (LAMA)

Increased intraocular pressure is a known potential side effect of corticosteroids, including inhaled corticosteroids found in Trelegy 1. This necessitates finding an alternative treatment approach that avoids steroids.

Non-Steroid Treatment Options

First-Line Alternative: Leukotriene Receptor Antagonists

• Montelukast (Singulair) and zafirlukast (Accolate) are the two widely available LTRAs 1
• Montelukast is taken once daily, while zafirlukast is taken twice daily 1
• LTRAs work by interfering with the pathway of leukotriene mediators released from mast cells, eosinophils, and basophils 1
• They provide good control of asthma symptoms in many patients without the use of corticosteroids 1
• LTRAs have the advantages of ease of use and high rates of compliance 1

Other Non-Steroid Options to Consider

Anticholinergics (LAMA only)

• Tiotropium bromide can be used as a standalone therapy without ICS 2, 3
• Recent evidence suggests tiotropium alone may be effective in some patients 3, 4
• Caution: The patient is already on Trelegy which contains a LAMA component, so this would be continuing part of their current regimen rather than a completely new approach 5

Theophylline

• Sustained-release theophylline can be used as an alternative therapy for mild persistent asthma 1
• It is a mild to moderate bronchodilator 1
• Requires monitoring of serum theophylline concentration 1
• Less preferred than LTRAs due to narrow therapeutic window and potential for drug interactions 1

Cromolyn Sodium and Nedocromil

• These medications stabilize mast cells and interfere with chloride channel function 1
• Can be used as alternative therapy for mild persistent asthma 1
• Also useful as preventive treatment before exercise or unavoidable exposure to known allergens 1
• Less commonly used in current practice compared to other options 1

Treatment Algorithm Based on Asthma Severity

1. For Mild Persistent Asthma:

   • First choice: Montelukast (once daily) or zafirlukast (twice daily) 1
   • Alternative: Cromolyn, nedocromil, or theophylline 1

2. For Moderate Persistent Asthma:

   • Consider combination therapy: LTRA plus LAMA (tiotropium) 3, 5
   • Recent studies show tiotropium add-on significantly decreased risk and rate of exacerbations compared to increasing ICS+LABA dose 4

3. For Severe Persistent Asthma:

   • Consider biologics like omalizumab (anti-IgE) if the patient has allergic asthma 1
   • Combination of non-steroid controllers may be necessary 5

Important Considerations and Caveats

• Efficacy comparison: LTRAs are generally less effective than ICS for controlling asthma but provide a viable non-steroid alternative 1
• Monitoring: More frequent monitoring of asthma symptoms and lung function may be necessary when switching from a potent triple therapy like Trelegy to a non-steroid alternative 1
• Rescue medication: Ensure the patient has access to a short-acting beta-agonist (SABA) like albuterol for rescue use 1
• Exacerbation risk: Be aware that removing ICS may increase the risk of exacerbations in some patients; have an action plan ready 6
• Follow-up: Schedule a follow-up visit within 2-4 weeks of changing therapy to assess response 1

Conclusion for This Patient

For this specific patient with increased intraocular pressure on Trelegy, starting with montelukast as a daily controller medication is the most appropriate non-steroid option 1. If asthma control is inadequate, consider adding tiotropium alone (without the ICS component of their previous Trelegy) 3, 4.