Current guidance states that advanced therapies should only be used when adherence to maintenance therapy (inhaled corticosteroid/long-acting β-agonist) has been proven. This is based on the costs of advanced therapies, the fact that they were generally trialled as add-ons to maintenance therapy, and the assumed efficacy of maintenance therapy in the majority of adherent patients. In this pro/con debate, we argue that such a rigid view of access downplays the complex and multifactorial nature of poor adherence. Not only does the evidence indicate a role for psychosocial factors in both poor adherence and poor asthma outcomes, failure of maintenance therapy itself may be a driver of poor adherence behaviours. Some individuals at high risk of poor asthma outcomes will therefore also have poor adherence that is not rapidly amenable to intervention. Rather than punishing them for factors outside of their control, they should be allowed access to advanced therapies in order to reduce their adverse risk resulting from uncontrolled asthma.
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