What are the alternatives to Breztri (budesonide, glycopyrrolate, formoterol) for Chronic Obstructive Pulmonary Disease (COPD) management?

Alternatives to Breztri for COPD Management

For patients requiring alternatives to Breztri (budesonide/glycopyrrolate/formoterol), other dual or triple therapy combinations should be considered based on symptom severity, exacerbation history, and lung function.

Alternative Triple Therapy Options

• Other triple therapy combinations (ICS/LAMA/LABA) in single or multiple inhalers can be considered for patients with severe COPD (GOLD category D) 1
• Fluticasone/umeclidinium/vilanterol (Trelegy Ellipta) is an alternative single-inhaler triple therapy option for patients with moderate to severe COPD with persistent symptoms and high exacerbation risk 2
• Beclomethasone/glycopyrronium/formoterol is another single-inhaler triple therapy alternative for patients with FEV₁ <50% predicted and history of exacerbations 3

Dual Therapy Options

• LAMA/LABA combinations (e.g., umeclidinium/vilanterol, glycopyrronium/formoterol, tiotropium/olodaterol) are appropriate alternatives for patients with less severe disease or those who cannot tolerate ICS 1, 4
• ICS/LABA combinations (e.g., fluticasone/salmeterol, budesonide/formoterol) may be appropriate for patients with features of asthma-COPD overlap or high blood eosinophil counts 1
• Glycopyrronium/formoterol (Bevespi Aerosphere) specifically provides an alternative that removes the ICS component while maintaining bronchodilation effects 4

Monotherapy Options

• Long-acting muscarinic antagonists (LAMAs) such as tiotropium, umeclidinium, or glycopyrronium can be used as monotherapy in patients with milder disease (GOLD Group A or B) 1
• Long-acting beta-agonists (LABAs) like formoterol or salmeterol can be used as monotherapy, though they are generally less preferred than LAMAs 1, 5

Patient-Specific Selection Criteria

• For patients with high exacerbation risk (≥2 exacerbations/year or ≥1 hospitalization): Triple therapy or LAMA/LABA is recommended 1, 2
• For patients with blood eosinophil counts ≥150 cells/mm³: Consider ICS-containing regimens 1
• For patients with chronic bronchitis and FEV₁ <50% predicted: Consider adding roflumilast to current therapy if still experiencing exacerbations 1
• For former smokers with persistent exacerbations despite optimal therapy: Consider adding a macrolide (with caution regarding antibiotic resistance) 1

Special Considerations

• Pneumonia risk is higher with ICS-containing regimens (NNH of 33 patients treated for one year), which should be considered when selecting therapy 3, 6
• Patients with cardiovascular comorbidities should be monitored carefully when using LABA-containing medications 1
• Spacer devices can improve drug delivery for patients with suboptimal inhalation technique when using MDI-based therapies 7

Treatment Algorithm

1. Assess COPD severity and exacerbation history:

   • Low symptom burden (GOLD A): LAMA or LABA monotherapy 1
   • Moderate symptoms (GOLD B): LAMA/LABA dual therapy 1
   • High exacerbation risk (GOLD C/D): LAMA/LABA or triple therapy 1, 2

2. If switching from Breztri due to side effects:

   • If pneumonia is a concern: Consider LAMA/LABA without ICS 6
   • If cardiovascular effects are a concern: Consider regimens without formoterol 1

3. If switching from Breztri due to inadequate control:

   • Consider adding roflumilast for patients with chronic bronchitis and persistent exacerbations 1
   • Consider macrolide therapy for former smokers with persistent exacerbations 1

4. For patients requiring simplified regimens:

   • Once-daily options like fluticasone/umeclidinium/vilanterol may improve adherence 1

Common Pitfalls to Avoid

• Discontinuing ICS abruptly in patients with asthma-COPD overlap can lead to deterioration 1
• Underestimating the importance of proper inhaler technique when switching between devices 7
• Failing to reassess therapy effectiveness after switching medications 1
• Not considering comorbidities when selecting alternative therapies 1