Should a 51-year-old male with Chronic Obstructive Pulmonary Disease (COPD) on albuterol (Salbutamol) and previously taking Spiriva (Tiotropium) be considered for addition of an Inhaled Corticosteroid (ICS) such as Breo (Fluticasone furoate/Vilanterol)?

From the Guidelines

Adding Breo (fluticasone/vilanterol) to your COPD regimen may be appropriate, as the most recent and highest quality study suggests that ICS/LABA combination therapy can improve lung function and reduce exacerbations in patients with COPD 1. For a 51-year-old male currently using albuterol and previously on Spiriva (tiotropium), adding an inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combination like Breo could help if you're experiencing frequent exacerbations or have elevated eosinophil counts. Breo is typically dosed as one inhalation (100/25 mcg or 200/25 mcg) once daily. You would continue your albuterol as needed for rescue therapy, but discuss with your doctor whether to continue or discontinue Spiriva, as some patients benefit from triple therapy (LABA/LAMA/ICS). Key points to consider include:

• The potential benefits of adding an ICS component to reduce inflammation in the airways, which can decrease exacerbation frequency and improve lung function in appropriate COPD patients 1
• The risks associated with ICS therapy, including pneumonia, oral thrush, and potential bone density effects 1
• The importance of proper assessment by your healthcare provider to determine if the benefits outweigh the risks in your case, taking into account your specific COPD phenotype, exacerbation history, and lung function 1 It's also important to note that the 2023 Canadian Thoracic Society guideline recommends ICS/LABA combination therapy over LAMA/LABA dual therapy in individuals with COPD and concomitant asthma, and suggests considering triple therapy (LABA/LAMA/ICS) in patients with stable COPD at low risk of exacerbations and moderate to high symptom burden 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Adding an ICS to Existing COPD Treatment

The consideration of adding an inhaled corticosteroid (ICS) such as Breo to the treatment regimen of a 51-year-old male with COPD, who is already on albuterol and was taking Spiriva, is a decision that should be based on the patient's specific condition and response to current therapy.

Evidence from Studies

• A study from 2008 2 compared the efficacy of fluticasone propionate/salmeterol (FSC) with ipratropium bromide/albuterol (IB/ALB) in patients with COPD, both reversible and non-reversible.
• The study found that FSC significantly increased FEV(1)AUC(0-6h) from baseline in both reversible and non-reversible patients, with a larger magnitude of improvement in reversible patients.
• Additionally, FSC treatment resulted in significant improvements in Transition Dyspnea Index (TDI) scores, overall daytime diary symptom scores, and nocturnal symptom measures compared to IB/ALB in both reversibility groups.
• The study suggests that the addition of an ICS like fluticasone propionate to a long-acting beta-agonist (LABA) such as salmeterol may provide greater clinical benefit than treatment with a combination of an anticholinergic and a short-acting beta-agonist (SABA) like ipratropium bromide/albuterol.

Considerations for Treatment Adjustment

• The decision to add Breo, which contains fluticasone furoate and vilanterol, to the patient's treatment regimen should consider the patient's current symptoms, lung function, and response to existing medications.
• It is also important to consider the potential benefits and risks of adding an ICS, including the potential for increased risk of pneumonia, which has been associated with ICS use in patients with COPD 2.