Is Breztri (budesonide, glycopyrrolate, and formoterol), 2 puffs twice daily (BID), an appropriate treatment for Chronic Obstructive Pulmonary Disease (COPD)?

Breztri (Budesonide/Glycopyrronium/Formoterol) for COPD Treatment

Breztri (budesonide/glycopyrrolate/formoterol), administered as 2 puffs twice daily, is an appropriate treatment for COPD patients with moderate to severe disease who have a history of exacerbations despite optimal bronchodilator therapy. This triple therapy combination provides superior exacerbation reduction compared to dual therapies and improves lung function, symptoms, and quality of life 1.

Efficacy of Triple Therapy in COPD

• Triple therapy with budesonide/glycopyrronium/formoterol significantly reduces the rate of moderate to severe COPD exacerbations compared to dual therapies (budesonide/formoterol or glycopyrronium/formoterol) 1.
• Breztri has demonstrated improved lung function, reduced dyspnea, decreased rescue medication requirements, and enhanced health-related quality of life compared to dual therapies 1.
• The ETHOS trial showed that Breztri with the higher budesonide dose (320 μg) significantly reduced all-cause mortality compared with glycopyrronium/formoterol dual therapy (hazard ratio 0.51; 95% CI 0.33-0.80) 2.

Appropriate Patient Selection

• Breztri is indicated for maintenance treatment of COPD, particularly in patients whose disease is inadequately controlled with dual therapy (ICS/LABA or LAMA/LABA) 1.
• Real-world data indicates that Breztri is being prescribed to patients with COPD who are experiencing symptoms and exacerbations despite current therapy, and among patients with various chronic comorbidities, most often cardiopulmonary-related 3.
• According to guidelines, triple therapy is considered appropriate for patients with more severe COPD (GOLD category D) 4.

Mechanism and Components

• Breztri combines three medications with different mechanisms of action 1:
  • Budesonide: An inhaled corticosteroid (ICS) that reduces airway inflammation
  • Glycopyrronium: A long-acting muscarinic antagonist (LAMA) that blocks acetylcholine receptors, reducing bronchoconstriction
  • Formoterol: A long-acting β2-agonist (LABA) that relaxes airway smooth muscle

Benefits of Single Inhaler Triple Therapy

• Fixed-dose combination therapy in a single inhaler can enhance compliance by decreasing the number of medications and daily doses 5.
• The co-suspension delivery technology in the Aerosphere inhaler provides consistent medication delivery 1.
• Single inhaler triple therapy simplifies the treatment regimen, which may improve adherence in patients with COPD 5.

Safety Considerations

• Breztri is generally well tolerated, with a safety profile similar to that of the individual components 1.
• Inhaled corticosteroid therapy may increase the risk of pneumonia in COPD patients 4, 6.
• The American College of Chest Physicians notes that for COPD patients, the number needed to treat is four patients for one year to prevent one moderate to severe exacerbation with triple therapy versus dual bronchodilator therapy 6.
• The number needed to harm is 33 patients for one year to cause one pneumonia, suggesting a favorable risk-benefit ratio 6.

Treatment Algorithm

1. Initial Assessment: Evaluate COPD severity, exacerbation history, and response to current therapy 4.
2. Consider Breztri when:
   • Patient has moderate to severe COPD with FEV₁ <50-60% predicted 6
   • History of exacerbations despite optimal bronchodilator therapy 6
   • Inadequate symptom control on dual therapy (LAMA/LABA or ICS/LABA) 1
3. Dosing: Administer 2 puffs twice daily via the Aerosphere inhaler 1
4. Monitoring:
   • Assess for improvement in lung function, symptoms, and exacerbation frequency 1
   • Monitor for potential adverse effects, particularly pneumonia 4, 6

Conclusion

Breztri represents an effective option for COPD management, particularly in patients with moderate to severe disease and a history of exacerbations. The combination of three medications with different mechanisms of action in a single inhaler provides comprehensive bronchodilation and anti-inflammatory effects while potentially improving treatment adherence.