What are alternative triple therapy options for Chronic Obstructive Pulmonary Disease (COPD) in a patient who did not respond to Trelegy (fluticasone furoate/umeclidinium/vilanterol)?

From the Guidelines

For a patient who did not respond to Trelegy for COPD triple therapy, alternative options include Breztri Aerosphere (budesonide/glycopyrrolate/formoterol) or creating a custom triple therapy using separate inhalers such as an ICS/LABA combination plus a LAMA inhaler, as recommended by the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1. When considering alternative triple therapy options, it is essential to assess the patient's specific symptoms, exacerbation history, lung function, and ability to use different inhaler devices. The patient's poor response to Trelegy may be due to several factors, including a poor response to fluticasone, umeclidinium, or vilanterol, or the delivery system might not have been optimal for the patient's inhalation technique 1. Some key points to consider when switching therapies include:

• The patient's phenotype of COPD and how it may respond to different medications
• The importance of proper inhaler technique education and close monitoring after switching to ensure the new regimen is effective
• The potential benefits and risks of adding macrolide maintenance therapy or roflumilast to the treatment regimen, as suggested by the 2023 Canadian Thoracic Society guideline 1
• The lack of evidence supporting the use of theophylline or systemic oral corticosteroids for maintenance treatment in COPD, as stated in the 2023 Canadian Thoracic Society guideline 1 It is crucial to prioritize the patient's morbidity, mortality, and quality of life when making decisions about alternative triple therapy options, and to base these decisions on the most recent and highest-quality evidence available, such as the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1.

From the FDA Drug Label

The safety and effectiveness of STIOLTO RESPIMAT in asthma have not been established. STIOLTO RESPIMAT is not indicated for the treatment of asthma [see Contraindications (4)] STIOLTO RESPIMAT is a combination of tiotropium bromide and olodaterol indicated for long-term, once-daily maintenance treatment of patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema The efficacy of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg in the treatment of subjects with COPD was evaluated in 6 randomized, double-blind, parallel-group clinical trials in adult subjects aged 40 years and older

Alternative triple therapy options for Chronic Obstructive Pulmonary Disease (COPD) in a patient who did not respond to Trelegy (fluticasone furoate/umeclidinium/vilanterol) may include:

• Tiotropium and olodaterol (STIOLTO RESPIMAT) in combination with an inhaled corticosteroid, as STIOLTO RESPIMAT is indicated for long-term, once-daily maintenance treatment of patients with COPD 2
• Fluticasone propionate and salmeterol inhalation powder in combination with a long-acting muscarinic antagonist (LAMA), as fluticasone propionate and salmeterol inhalation powder has been evaluated in clinical trials for the treatment of COPD 3 Note that these options should be considered on a case-by-case basis, taking into account the individual patient's medical history, current medications, and response to previous treatments.

From the Research

Alternative Triple Therapy Options for COPD

In patients who did not respond to Trelegy (fluticasone furoate/umeclidinium/vilanterol), alternative triple therapy options can be considered. The following are some alternatives:

• Budesonide/glycopyrronium/formoterol fumarate metered dose inhaler (BGF MDI) 4
• Beclomethasone dipropionate/formoterol fumarate/glycopyrronium bromide (BDP/FOR/GLY) 5, 6
• Budesonide/glycopyrronium bromide/formoterol fumarate (BUD/GLY/FOR) 5

Efficacy and Safety of Alternative Triple Therapies

Studies have shown that these alternative triple therapies have comparable efficacy to Trelegy in reducing exacerbations and improving lung function and symptoms in patients with moderate to very severe COPD 4, 5, 6. However, the risk of pneumonia associated with ICS use should be assessed on an individual basis 5, 7.

Considerations for Alternative Triple Therapies

When considering alternative triple therapies, it is essential to evaluate the patient's response to treatment and identify those who are most likely to benefit from triple therapy 7. The role of elevated blood eosinophils as a biomarker for ICS treatment is currently debated, and further prospective evidence is required 7. Additionally, the potential for treating patients who experience further exacerbations on dual bronchodilation according to phenotype should be considered 7.