What are the management options for a patient on Trelegy (fluticasone furoate/umeclidinium/vilanterol) still experiencing a cough, according to Australian cold management guidelines?

Management Options for Persistent Cough in a Patient on Trelegy

For a patient on Trelegy (fluticasone furoate/umeclidinium/vilanterol) who is still experiencing cough, a trial of inhaled ipratropium bromide is recommended as the first-line treatment option. 1

Assessment of Cough Duration and Type

• Determine if the cough is postinfectious (3-8 weeks following respiratory infection) or chronic (>8 weeks) 1
• Evaluate for potential contributing factors including:
  • Postviral airway inflammation
  • Bronchial hyperresponsiveness
  • Mucus hypersecretion
  • Impaired mucociliary clearance
  • Upper airway cough syndrome (UACS)
  • Gastroesophageal reflux disease (GERD) 1

Treatment Algorithm for Persistent Cough in a Patient on Trelegy

First-line options:

• Inhaled ipratropium bromide - The only inhaled anticholinergic agent recommended for cough suppression in upper respiratory infections or chronic bronchitis 1
  • Note: Although the patient is already on umeclidinium (a LAMA) in Trelegy, additional ipratropium may provide further cough suppression benefits

Second-line options (if ipratropium is ineffective):

• Inhaled corticosteroids - Consider adjusting the dose if cough persists despite ipratropium and adversely affects quality of life 1
  • Note: The patient is already on fluticasone furoate in Trelegy, but dose adjustment might be considered

Third-line options:

• Short course of oral prednisone (30-40 mg daily for a short period) for severe paroxysms of cough when other common causes have been ruled out 1

Fourth-line options:

• Central acting antitussive agents such as codeine and dextromethorphan when other measures fail 1
  • These are recommended for short-term symptomatic relief in chronic bronchitis 1

Additional Supportive Measures

• Hypertonic saline solution - Recommended on a short-term basis to increase cough clearance in patients with bronchitis 1
• Huffing technique - Should be taught as an adjunct to other methods of sputum clearance in COPD patients 1
• Avoid manually assisted cough in patients with airflow obstruction like COPD as it may be detrimental 1

Important Considerations and Caveats

• Antibiotics have no role in postinfectious cough unless there is evidence of bacterial infection 1
• Albuterol is not recommended for acute or chronic cough not due to asthma 1
• Over-the-counter combination cold medications (except older antihistamine-decongestants) are not recommended for cough suppression 1
• If cough persists beyond 8 weeks, consider diagnoses other than postinfectious cough 1
• Evaluate for potential Bordetella pertussis infection if cough has lasted ≥2 weeks with paroxysms of coughing, post-tussive vomiting, or inspiratory whooping sound 1

Monitoring Response

• Assess response to therapy within 1-2 weeks
• If cough persists despite sequential therapies, consider systematic evaluation for other common causes of chronic cough (UACS, asthma, NAEB, and GERD) 1
• For patients with persistent symptoms despite triple therapy, consider that Trelegy may not offer additional benefits over dual therapy for some patients 2, 3