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Review
. 2025 Feb;80(2):380-394.
doi: 10.1111/all.16436. Epub 2024 Dec 16.

The Bronchodilator and Anti-Inflammatory Effect of Long-Acting Muscarinic Antagonists in Asthma: An EAACI Position Paper

I Agache  1 , I M Adcock  2 , C A Akdis  3 , M Akdis  3 , G Bentabol-Ramos  4 , M van den Berge  5 , C Boccabella  6 , W G Canonica  7   8 , C Caruso  9 , M Couto  10 , I Davila  11 , D Drummond  12 , J Fonseca  13 , A Gherasim  14 , S Del Giacco  15 , D J Jackson  16 , M Jutel  17   18 , A Licari  19 , S Loukides  20 , A Moreira  21   22   23 , M Mukherjee  24 , I Ojanguren  25 , O Palomares  26 , A Papi  27 , L Perez de Llano  28 , O J Price  29   30 , M Rukhazde  31   32 , M H Shamji  33   34 , D Shaw  35 , S Sanchez-Garcia  36 , A Testera-Montes  37 , M J Torres  37 , I Eguiluz-Gracia  37
Affiliations
Review

The Bronchodilator and Anti-Inflammatory Effect of Long-Acting Muscarinic Antagonists in Asthma: An EAACI Position Paper

I Agache et al. Allergy. 2025 Feb.

Abstract

As cholinergic innervation is a major contributor to increased vagal tone and mucus secretion, inhaled long-acting muscarinic antagonists (LAMA) are a pillar for the treatment of chronic obstructive pulmonary disease and asthma. By blocking the muscarinic receptors expressed in the lung, LAMA improve lung function and reduce exacerbations in asthma patients who remained poorly controlled despite treatment with inhaled corticosteroids and long-acting β2 agonists. Asthma guidelines recommend LAMA as a third controller to be added on before the initiation of biologicals. In addition to bronchodilation, LAMA also exert anti-inflammatory and anti-fibrotic effects by inhibiting muscarinic receptors present in neutrophils, macrophages, fibroblasts and airway smooth muscle cells. Thus, besides bronchodilation, LAMA might provide additional therapeutic effects, thereby supporting an endotype-driven approach to asthma management. The Position Paper, developed by the Asthma Section of the European Academy of Allergy and Clinical Immunology, discusses the main cholinergic pathways in the lung, reviews the findings of significant clinical trials and real-life studies on LAMA use in asthma, examines the placement of these drugs in asthma clinical guidelines, and considers the potential for personalised medicine with LAMA in both adult and paediatric asthma patients.

Keywords: acetylcholine; asthma; bronchodilator; endotype; long‐acting muscarinic antagonists; precision medicine.

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References

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