What is the next inhaler option for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is not responding to Trelegy Ellipta (fluticasone/fumeclidine/vilanterol)?

From the Guidelines

For a COPD patient not responding to Trelegy Ellipta, the next option would typically be adding roflumilast (Daliresp) 500 mcg once daily if the patient has chronic bronchitis with frequent exacerbations, as recommended by the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1. When considering treatment intensification for a patient with COPD who is not responding to Trelegy Ellipta, it's essential to assess the patient's specific COPD phenotype, exacerbation history, and symptom pattern.

• The patient's current symptoms and exacerbation history should be evaluated to determine the best course of action.
• According to the 2023 Canadian Thoracic Society guideline, adding macrolide maintenance therapy, such as azithromycin, may be considered for patients with a high risk of exacerbations and normal QT interval on ECGs, no significant drug interactions, and no evidence of indolent or active infection with atypical mycobacteria 1.
• Roflumilast has been shown to reduce moderate and severe exacerbations in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations, as noted in the 2017 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease report 1.
• It's also crucial to ensure proper inhaler technique and adherence to the current regimen before changing therapy, as well as ruling out other conditions that might explain the poor response to Trelegy, such as heart failure or bronchiectasis.
• Pulmonary rehabilitation should be considered alongside medication adjustments to improve the patient's overall quality of life and reduce symptoms.
• The choice of next steps should be individualized based on the patient's specific needs and medical history, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Inhaler Options for COPD Patients Not Responding to Trelegy Ellipta

• For patients with Chronic Obstructive Pulmonary Disease (COPD) who are not responding to Trelegy Ellipta, alternative treatment options may include other triple therapy combinations or different classes of medications 2, 3, 4.
• One potential option is a single inhaler triple therapy with an inhaled corticosteroid, a long-acting β2-agonist, and a long-acting muscarinic antagonist, such as beclometasone dipropionate, formoterol fumarate, and glycopyrronium 4.
• Another option is the use of a phosphodiesterase 4 inhibitor, such as roflumilast, which has been shown to reduce the frequency of exacerbations in patients with severe COPD and a history of exacerbations 5.
• Long-acting muscarinic antagonists (LAMAs), such as tiotropium bromide, aclidinium bromide, and glycopyrrolate, may also be considered as alternative or add-on treatments for COPD patients not responding to Trelegy Ellipta 6.

Considerations for Treatment Selection

• The choice of next inhaler option should be based on individual patient factors, such as disease severity, exacerbation history, and comorbidities 3, 4.
• Patients with a history of exacerbations may benefit from treatments that have been shown to reduce exacerbation risk, such as triple therapy combinations or phosphodiesterase 4 inhibitors 3, 5.
• The potential benefits and risks of each treatment option should be carefully considered, including the risk of side effects such as pneumonia or weight loss 4, 5.