What is the recommended treatment for a patient with obstructive lung disease, likely chronic obstructive pulmonary disease (COPD) or asthma, based on spirometry results?

From the Guidelines

The patient with obstructive lung disease and spirometry results showing an FEV1/FVC ratio of 58% and FEV1 of 64% post-bronchodilator should be treated with a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA) combination therapy, as this has been shown to improve lung function and reduce exacerbation risk 1. Given the patient's FEV1/FVC ratio and FEV1 percentage, it is likely that they have moderate to severe COPD.

• The 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD recommends LAMA/LABA combination therapy for patients with moderate to severe COPD, especially those with a high risk of exacerbations 1.
• This guideline also suggests that LAMA/LABA single inhaled dual therapy is preferred over ICS/LABA inhaled combination therapy, considering the additional improvements in lung function and the lower rates of adverse events such as pneumonia 1.
• However, ICS/LABA combination therapy should be used in individuals with concomitant asthma, and triple inhaled ICS/LAMA/LABA combination therapy may be considered for patients with high-risk COPD 1. The patient's treatment plan should be individualized based on their symptom burden, risk of exacerbations, and response to treatment.
• Regular follow-up appointments and spirometry tests should be scheduled to monitor the patient's condition and adjust their treatment plan as needed.
• Additionally, the patient should be advised to quit smoking, participate in pulmonary rehabilitation, and receive vaccinations against influenza and pneumococcal disease to improve their overall health and reduce their risk of exacerbations.

From the FDA Drug Label

The use of Wixela Inhub is contraindicated in the following conditions: • Primary treatment of status asthmaticus or other acute episodes of asthma or COPD where intensive measures are required • Severe hypersensitivity to milk proteins or demonstrated hypersensitivity to fluticasone propionate, salmeterol, or any of the excipients

The patient's spirometry results show an FEV1/FVC ratio of 58% and an FEV1 of 64% post-bronchodilator, indicating obstructive lung disease.

• The recommended treatment for a patient with obstructive lung disease, likely COPD or asthma, is a combination of medications, including a long-acting beta2-adrenergic agonist (LABA) and an inhaled corticosteroid (ICS).
• The dosage of Wixela Inhub for asthma is 1 inhalation twice daily, with the starting dosage strength based on the patient's disease severity.
• The dosage of Wixela Inhub for COPD is 1 inhalation of Wixela Inhub 250/50 twice daily. However, the FDA drug label does not provide specific guidance on the treatment of patients with these exact spirometry results. Therefore, the treatment should be individualized based on the patient's specific condition and medical history, and the patient should be monitored closely for any adverse effects. 2 2 2

From the Research

Spirometry Results Interpretation

The patient's spirometry results show an FEV1/FVC ratio of 58% post-bronchodilator and an FEV1 of 64% post-bronchodilator, indicating obstructive lung disease, likely chronic obstructive pulmonary disease (COPD) or asthma.

Treatment Recommendations

Based on the spirometry results, the following treatment options are recommended:

• For mild symptoms, initial treatment with a long-acting muscarinic antagonist (LAMA) is recommended 3.
• If symptoms are uncontrolled with monotherapy, dual therapy with a LAMA/long-acting beta2 agonist (LABA) combination should be initiated 3.
• Triple therapy with a LAMA/LABA/inhaled corticosteroid (ICS) combination may be considered for patients with severe disease or those who are not controlled with dual therapy, but it increases the risk of pneumonia 4, 3.
• The LABA/LAMA combination is the highest ranked treatment group to reduce COPD exacerbations, followed by LAMA, and then LABA 5.

Comparison of Treatment Options

The following comparisons between treatment options have been made:

• LAMA+LABA versus LABA+ICS: similar benefits for exacerbations and quality of life, but LAMA+LABA offers a larger improvement in FEV1 and a slightly lower risk of pneumonia 4.
• LAMA versus LABA: LAMA may have an advantage over LABA for preventing COPD exacerbations 5.
• Combination therapies (LAMA+LABA or LABA+ICS) versus monotherapies: combination therapies appear more effective for improving symptom and quality-of-life scores 5, 6.

Safety Considerations

The following safety considerations should be taken into account:

• ICS-containing inhalers are associated with an increased risk of pneumonia 5, 4.
• The risk of serious adverse events is similar between LAMA+LABA and LABA+ICS 4.
• All-cause death may be lower with LABA+ICS, but the absolute risk is low 4.