What are common examples of triple therapy inhalers for COPD (Chronic Obstructive Pulmonary Disease) patients with raised eosinophils?

Common Triple Therapy Inhalers for COPD with Raised Eosinophils

Single-inhaler triple therapy (SITT) containing LAMA/LABA/ICS is the recommended treatment for COPD patients with raised eosinophils (≥300 cells/μL) who are at high risk of exacerbations. 1, 2

Available Triple Therapy Options

FDA-Approved Single-Inhaler Triple Therapies:

• Fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI)

  • Once-daily dosing
  • Particularly beneficial for patients with blood eosinophil counts ≥300 cells/μL
  • Demonstrated mortality benefit in the ETHOS study 1, 3

• Budesonide/formoterol/glycopyrronium

  • Multiple daily dosing
  • Effective for patients with frequent exacerbations and elevated eosinophils 4

• Beclometasone/formoterol/glycopyrronium

  • Multiple daily dosing
  • Suitable for patients with severe COPD and eosinophilic inflammation 4

Patient Selection for Triple Therapy

Triple therapy is particularly indicated for:

• Patients with blood eosinophil counts ≥300 cells/μL 1, 2
• Those with frequent exacerbations despite dual therapy 1
• Patients with COPD-asthma overlap syndrome 2, 4
• Individuals with severe to very severe COPD 4

Clinical Benefits of Triple Therapy in Eosinophilic COPD

• Exacerbation reduction: NNT=4 to prevent one moderate-severe exacerbation per year 1
• Mortality benefit: Demonstrated with moderate-dose ICS in triple therapy 1
• Improved lung function: Greater improvements in FEV1 compared to dual therapies 5, 3
• Enhanced quality of life: Better symptom control and health status 5

Important Considerations

Efficacy

• Single-inhaler triple therapy shows incremental benefits compared to multiple-inhaler triple therapy 1
• Moderate-dose ICS in triple therapy provides mortality benefit without increased exacerbation reduction compared to low-dose ICS 1

Safety

• Pneumonia risk: Higher with ICS-containing regimens (NNH=33) 1, 2
• The risk-benefit ratio favors triple therapy in appropriate patients (NNT=4 vs NNH=33) 1
• Pneumonia is recognized as a class effect of ICS-containing therapies 1

Treatment Persistence

• Do not withdraw ICS in patients with blood eosinophil counts ≥300 cells/μL 1, 2
• Withdrawing ICS can worsen health status, lung function, and increase exacerbation risk, especially in those with elevated eosinophils 1

When Triple Therapy May Not Be Appropriate

• Patients with blood eosinophil counts <100 cells/μL may not benefit significantly from the ICS component 2
• Low risk of exacerbations (no history in past year) 2
• Significant ICS-related adverse effects 2

Additional Therapies for Refractory Cases

For patients who continue to exacerbate despite triple therapy:

• Consider adding macrolide maintenance therapy (e.g., azithromycin) in appropriate patients with normal QT interval 1, 2
• Alternative options include roflumilast or N-acetylcysteine, especially for those with chronic bronchitic phenotype 1

Triple therapy represents an important treatment option for COPD patients with elevated eosinophils, offering significant benefits in reducing exacerbations and mortality when used appropriately.