What are the next steps for a patient with Chronic Obstructive Pulmonary Disease (COPD) not controlled on Trelegy (fluticasone furoate/umeclidinium/vilanterol)?

Management of COPD Not Controlled on Trelegy

For patients with COPD not controlled on Trelegy (fluticasone furoate/umeclidinium/vilanterol), the next step should be to consider adding a phosphodiesterase-4 inhibitor such as roflumilast, especially in patients with persistent exacerbations despite triple therapy.

Assessment of Current Therapy

Before adding additional medications, ensure:

• Proper inhaler technique has been verified, as up to 76% of COPD patients make important errors when using their inhalers 1
• The diagnosis of COPD is correct and other conditions are not mimicking or exacerbating COPD symptoms 1
• Current symptoms and limitations are properly documented to establish a baseline 1

Therapeutic Options When Triple Therapy is Insufficient

Consider Adding PDE4 Inhibitors

• Phosphodiesterase-4 inhibitors (such as roflumilast) can be considered as add-on therapy for patients whose condition is not controlled by triple therapy 2
• These medications reduce airway inflammation and can decrease exacerbation rates (OR 0.78,95% CI 0.73 to 0.84) 2
• Most appropriate for patients with persistent symptoms or exacerbations despite optimal management with triple therapy 2

Evaluate for Home Nebulizer Therapy

• For patients with severe disease who remain symptomatic, high-dose bronchodilator treatment via nebulizer may provide additional benefit 1
• This should only be prescribed after formal assessment by a respiratory physician 1
• Assessment should include verification that optimal use has been made of current inhalers and that the patient demonstrates response to nebulized medication 1

Consider Theophyllines

• Theophyllines can be tried in patients with severe COPD not responding to other therapies 1
• These medications must be carefully monitored for side effects 1
• They may improve respiratory muscle strength and effectiveness, which could explain improvements in exercise tolerance 1

Management of Acute Exacerbations

If the patient is experiencing an acute exacerbation:

• Increase the dose of current bronchodilators 1
• Consider adding oral corticosteroids (typically 30mg daily for one week) if:
  • The patient is already on oral corticosteroids
  • There is a previously documented response to oral corticosteroids
  • Airflow obstruction fails to respond to increased bronchodilator dose 1
• Prescribe antibiotics if two or more of the following are present:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 1

Non-Pharmacological Approaches

• Encourage appropriate exercise within the limitations of the patient's airways obstruction 1
• Consider nutritional support if the patient is malnourished, as malnutrition is common in severe COPD and may contribute to mortality 1
• Ensure the patient has received influenza and pneumococcal vaccinations 1

Common Pitfalls to Avoid

• Avoid beta-blocking agents (including eyedrop formulations) in COPD patients 1
• Don't continue ineffective medications - if a treatment shows no benefit, it should be discontinued 1
• Avoid prescribing high-dose treatments including nebulized drugs without formal assessment 1
• Be aware that PDE4 inhibitors commonly cause gastrointestinal side effects (particularly diarrhea) and can be associated with weight loss and psychiatric symptoms 2

Follow-up and Monitoring

• Regular follow-up is essential to assess response to therapy
• If the patient fails to respond to additional therapies, consider referral to a specialist for further evaluation 1
• Monitor for side effects of added medications, particularly with theophyllines and PDE4 inhibitors 1, 2