What is the recommended use of Trelegy Ellipta (fluticasone furoate, umeclidinium, vilanterol) for patients with chronic obstructive pulmonary disease (COPD) or asthma?

Trelegy Ellipta (Fluticasone Furoate/Umeclidinium/Vilanterol) in COPD and Asthma Management

Trelegy Ellipta is recommended as a triple therapy for patients with moderate to severe COPD who have persistent symptoms and high exacerbation risk, particularly those with FEV₁ <60% predicted who are not adequately controlled on dual therapy. 1, 2

Indications for Use

• Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol) is indicated for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD) 3
• It is also indicated for maintenance treatment of asthma in patients aged 5 years and older 3
• It is not indicated for relief of acute bronchospasm 3

Dosing and Administration

• For COPD: One inhalation of Trelegy Ellipta 100/25 mcg (fluticasone furoate/vilanterol) with umeclidinium once daily 3
• For asthma in adults (18+ years): One inhalation of either 100/25 mcg or 200/25 mcg once daily 3
• For asthma in adolescents (12-17 years): One inhalation of 100/25 mcg once daily 3
• For younger children (5-11 years): One inhalation of 50/25 mcg once daily 3

Treatment Algorithm for COPD

Patient Stratification and Treatment Selection

1. Mild COPD with low symptom burden (CAT <10, mMRC 1):

   • Start with LAMA or LABA monotherapy 1

2. Moderate to severe COPD with moderate symptoms (CAT ≥10, mMRC ≥2) and FEV₁ <80% predicted:

   • LAMA/LABA dual therapy is recommended as initial maintenance therapy 1

3. Moderate to severe COPD with high exacerbation risk:

   • Triple therapy with LAMA/LABA/ICS (such as Trelegy Ellipta) is recommended 1, 2
   • High exacerbation risk is defined as ≥2 moderate exacerbations or ≥1 severe exacerbation (requiring hospitalization) in the past year 1

4. COPD Group D (according to GOLD):

   • Triple therapy is preferred, with consideration for roflumilast if FEV₁ <50% predicted and patient has chronic bronchitis 1
   • Consider macrolide in former smokers if symptoms or exacerbations persist 1

Clinical Evidence for Trelegy Ellipta

• Triple therapy with fluticasone furoate/umeclidinium/vilanterol has demonstrated greater efficacy compared to dual therapies in reducing the rate of moderate-severe exacerbations 4
• It improves trough FEV₁, quality of life, and reduces dyspnea compared to dual therapies 4, 5
• In real-world studies, patients treated with FF/UMEC/VI showed significant improvements in:
  • Modified British Medical Research Council dyspnea score 5
  • COPD Assessment Test scores 5
  • Reduction in COPD exacerbations 5
  • Lung function parameters including FEV₁, residual volume, and inspiratory capacity 5

Advantages of Single-Inhaler Triple Therapy

• Once-daily administration improves adherence compared to multiple inhalers 6
• The Ellipta device has shown good patient acceptance and preference 6
• Single-inhaler triple therapy (SITT) is preferred over multiple inhalers for administration of triple therapy 1

Cautions and Monitoring

• Increased risk of pneumonia in COPD patients using ICS-containing regimens 1, 3
• Monitor for Candida albicans infection of the mouth and pharynx 3
• Not for primary treatment of status asthmaticus or acute episodes of COPD 3
• Use with caution in patients with tuberculosis, fungal, bacterial, viral, or parasitic infections 3
• Risk of hypercorticism and adrenal suppression with high dosages or in susceptible individuals 3

Special Considerations

• For patients with features of asthma-COPD overlap, ICS-containing regimens are particularly important 2
• Blood eosinophil counts ≥150 cells/mm³ may predict better response to ICS-containing regimens 2
• Abrupt discontinuation of ICS in patients with asthma-COPD overlap should be avoided 2
• Consider cardiovascular comorbidities when using LABA-containing medications 2

Common Pitfalls to Avoid

• Failing to reassess therapy effectiveness after initiating or switching medications 2
• Not considering comorbidities when selecting therapy 2
• Using triple therapy in patients who may be adequately controlled on monotherapy or dual therapy 1
• Not providing proper inhaler technique education, which is crucial for effective medication delivery 1