What is the best inhalation therapy for a 62-year-old woman with stage 2 moderate Chronic Obstructive Pulmonary Disease (COPD), elevated eosinophil count, and history of exacerbations?

Management of Moderate COPD with History of Exacerbations and Elevated Eosinophil Count

Fluticasone furoate/vilanterol/umeclidinium Ellipta one inhalation once daily is the best recommendation for this patient with moderate COPD, history of exacerbations, and elevated eosinophil count. 1

Patient Assessment and Risk Factors

This 62-year-old woman presents with several important clinical features that guide treatment selection:

• Stage 2 moderate COPD
• mMRC score of 2 (indicating moderate symptom burden)
• History of two exacerbations in the past year requiring antibiotics and steroids
• Elevated blood eosinophil count of 342/μL
• No history of hospitalization for COPD

Treatment Recommendation Rationale

Triple Therapy Indication

The patient has clear indications for triple therapy (LAMA/LABA/ICS) based on:

1. Moderate COPD with significant symptoms (mMRC score of 2) 1
2. History of exacerbations (two in the past year) despite not being on any maintenance inhaler therapy 2
3. Elevated eosinophil count (>300 cells/μL), which predicts good response to ICS 1

Single-Inhaler Triple Therapy Benefits

Fluticasone furoate/umeclidinium/vilanterol offers several advantages:

• Reduced exacerbation risk: Triple therapy has been shown to significantly reduce exacerbation rates compared to LAMA/LABA therapy alone 3
• Mortality benefit: FF/UMEC/VI has demonstrated a 28% reduction in all-cause mortality compared to UMEC/VI in patients with COPD 3
• Improved adherence: Single-inhaler therapy improves adherence compared to multiple inhalers 4
• Real-world effectiveness: Recent studies show significant improvements in CAT scores and lung function with FF/UMEC/VI in usual care settings 5, 6

Why Not Other Options?

1. Vilanterol/umeclidinium (LAMA/LABA): While effective for symptom control, this dual therapy lacks the ICS component needed for a patient with elevated eosinophils and history of exacerbations 7

2. Salmeterol Diskus (LABA monotherapy): Insufficient for a patient with moderate COPD and exacerbation history; guidelines recommend against LABA monotherapy in this scenario 2

3. Tiotropium HandiHaler (LAMA monotherapy): While guidelines state LAMA monotherapy can reduce exacerbations 2, this patient's elevated eosinophil count and exacerbation history warrant ICS inclusion 1

Implementation Considerations

• Inhaler technique: Ensure proper training on Ellipta device use
• Monitoring: Regular assessment of symptom control, exacerbation frequency, and potential adverse effects
• Pneumonia risk: Monitor for signs of pneumonia, which is a potential risk with ICS-containing regimens 1
• Additional interventions: Consider pulmonary rehabilitation given the moderate symptom burden (mMRC score of 2) 1

Conclusion

Based on the most recent and highest quality evidence, fluticasone furoate/vilanterol/umeclidinium in a single Ellipta inhaler once daily provides the optimal balance of efficacy and convenience for this patient with moderate COPD, history of exacerbations, and elevated eosinophil count.