When should I use triple therapy versus Long-Acting Muscarinic Antagonist (LAMA)/Long-Acting Beta-Agonist (LABA) therapy in a patient with Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Triple therapy (inhaled corticosteroid/long-acting beta-agonist/long-acting muscarinic antagonist or ICS/LABA/LAMA) should be used in COPD patients who have persistent symptoms and exacerbations despite dual bronchodilator therapy with LAMA/LABA, particularly those with severe COPD, frequent exacerbations, or significant eosinophilia, as it has been shown to reduce mortality and exacerbation risk, as stated in the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1.

Key Considerations

• The decision to use triple therapy versus LAMA/LABA therapy should be based on the patient's symptom burden, risk of future exacerbations, and mortality risk.
• Triple therapy is recommended for patients with severe COPD (FEV1 <50% predicted), those experiencing two or more moderate exacerbations or one hospitalization per year, and patients with significant eosinophilia (blood eosinophil count ≥300 cells/μL) 1.
• LAMA/LABA therapy is appropriate for symptomatic COPD patients with less frequent exacerbations, lower eosinophil counts, and as initial therapy for those with moderate to severe symptoms 1.
• The addition of an ICS in triple therapy helps reduce inflammation and exacerbation risk, particularly in patients with eosinophilic inflammation, but increases pneumonia risk 1.
• Regular reassessment of symptoms, exacerbation history, and side effects should guide therapy adjustments 1.

Therapy Options

• Common triple therapy options include fluticasone/umeclidinium/vilanterol (Trelegy Ellipta), budesonide/glycopyrrolate/formoterol (Breztri Aerosphere), or separate inhalers containing ICS/LABA plus LAMA.
• LAMA/LABA therapy options include umeclidinium/vilanterol, tiotropium/olodaterol, or glycopyrrolate/formoterol.

Important Considerations

• Single-inhaler triple therapy (SITT) is favored over multiple inhalers due to potential increased benefits, increased adherence, and reduced chance of errors in inhaler technique 1.
• The environmental impact and global warming potential associated with metered dose inhalers (MDIs) should be considered when selecting an inhaler device 1.

From the Research

Treatment Options for COPD

When deciding between triple therapy and Long-Acting Muscarinic Antagonist (LAMA)/Long-Acting Beta-Agonist (LABA) therapy for a patient with Chronic Obstructive Pulmonary Disease (COPD), several factors should be considered:

• The severity of symptoms and the risk of exacerbations
• The patient's response to previous treatments
• The presence of other health conditions, such as asthma

Triple Therapy vs LAMA/LABA Therapy

Triple therapy, which includes an inhaled corticosteroid (ICS), a LABA, and a LAMA, has been shown to be effective in reducing the risk of exacerbations and improving lung function in patients with moderate to severe COPD 2. However, it may not be necessary for all patients, and the use of LAMA/LABA therapy may be sufficient for those with milder symptoms or fewer exacerbations 3, 4.

• Triple therapy may be preferred for patients with a history of exacerbations or those who have not responded to LAMA/LABA therapy alone
• LAMA/LABA therapy may be sufficient for patients with milder symptoms or fewer exacerbations

Patient-Specific Factors

The choice between triple therapy and LAMA/LABA therapy should be based on individual patient factors, including:

• The severity of symptoms, as measured by tools such as the COPD Assessment Test (CAT)
• The frequency and severity of exacerbations
• The presence of other health conditions, such as asthma or cardiovascular disease
• The patient's ability to adhere to treatment and use inhalers correctly

Clinical Evidence

Studies have shown that both triple therapy and LAMA/LABA therapy can be effective in improving lung function and reducing symptoms in patients with COPD 2, 5. However, the choice between these two options should be based on individual patient factors and the specific characteristics of the patient's disease.

• The DETECT study found that LAMA/LABA therapy was effective in improving lung function and reducing symptoms in patients with COPD, with similar results across different treatment groups 5
• The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends the use of LAMA/LABA therapy for patients with moderate to severe COPD, with or without a history of exacerbations 3, 4