What is an alternative to Breztri (budesonide, glycopyrrolate, and formoterol) for the maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)?

Alternatives to Breztri for COPD Maintenance Treatment

Fluticasone furoate/umeclidinium/vilanterol (Trelegy) is the recommended alternative to Breztri (budesonide/glycopyrrolate/formoterol) for maintenance treatment of COPD, as it demonstrates a 12% lower rate of exacerbations and 11% lower risk of all-cause mortality. 1

Triple Therapy Options

Triple therapy combines three medication classes to manage COPD:

1. Fluticasone furoate/umeclidinium/vilanterol (Trelegy)

   • Once-daily dosing
   • Associated with lower exacerbation rates and mortality compared to Breztri 1
   • Recommended by the American Thoracic Society for patients with moderate to severe COPD who continue to experience symptoms despite dual therapy 2

2. Glycopyrronium/formoterol (Bevespi Aerosphere)

   • Dual therapy option (LAMA/LABA)
   • Appropriate for patients who don't require ICS component 3
   • Can be considered if pneumonia risk is a concern

Treatment Selection Algorithm

Step 1: Assess Patient's Current Status

• Determine exacerbation history (frequency and severity)
• Evaluate symptom burden and lung function (FEV1)
• Check blood eosinophil count

Step 2: Select Appropriate Alternative Based on Clinical Presentation

For patients with:

• Moderate to severe COPD with frequent exacerbations:

  • Fluticasone furoate/umeclidinium/vilanterol (Trelegy) 2, 1

• Moderate COPD with fewer exacerbations:

  • LAMA/LABA combination (e.g., tiotropium/olodaterol or glycopyrronium/formoterol) 4, 2

• Mild to moderate COPD with minimal exacerbations:

  • LAMA monotherapy (e.g., tiotropium) or LABA monotherapy 4, 2

Evidence-Based Comparisons

Triple Therapy vs. Dual Therapy

• Triple therapy reduces exacerbations compared to LAMA or LABA monotherapy 4
• Triple therapy improves lung function and health-related quality of life, reaching minimally important clinical thresholds in both outcomes 4
• The combination of LAMA/LABA/ICS marginally improves risk for exacerbations compared to dual therapy 4

Comparative Effectiveness of Triple Therapies

• FF/UMEC/VI (Trelegy) users had 12% lower rate of annualized moderate-severe COPD exacerbations compared to BUD/GLY/FORM (Breztri) users 1
• FF/UMEC/VI demonstrated 11% lower risk of all-cause mortality at 12 months post-initiation compared to BUD/GLY/FORM 1

Important Considerations and Caveats

• Pneumonia Risk: ICS-containing regimens increase pneumonia risk, particularly in severe COPD 2

  • Number needed to harm: 33 patients treated for 1 year to cause one pneumonia 2

• Device Selection:

  • Consider patient's ability to generate adequate inspiratory flow
  • Single-inhaler therapy improves adherence and reduces technique errors 2

• Special Populations:

  • For patients with COPD-asthma overlap or high blood eosinophil counts, ICS-containing regimens are particularly beneficial 2
  • ICS should never be used as monotherapy in COPD 2

• Monitoring:

  • Reassess after 4-8 weeks of treatment and adjust therapy as needed 2
  • Treatment should be guided by symptom burden, exacerbation history, and lung function 2

For patients who continue to exacerbate despite triple therapy, consider adding a macrolide (e.g., azithromycin) in former smokers with normal QT interval 2.