What is the next step for a patient with emphysema and sarcoidosis not adequately controlled on dual therapy, such as Advair (fluticasone propionate/salmeterol) and albuterol (salbutamol), considering triple therapy with Trelegy (fluticasone furoate/umeclidinium/vilanterol)?

Triple Therapy for COPD: Trelegy (fluticasone furoate/umeclidinium/vilanterol)

For a patient with emphysema and sarcoidosis not adequately controlled on dual therapy (Advair and albuterol), triple therapy with Trelegy is strongly recommended as the next step to reduce mortality and improve symptom control. 1

Rationale for Triple Therapy

• Triple therapy with LAMA/LABA/ICS (Long-Acting Muscarinic Antagonist/Long-Acting Beta-Agonist/Inhaled Corticosteroid) is recommended for patients with moderate to high symptom burden (mMRC ≥2), impaired lung function (FEV1 <80% predicted), and high risk of exacerbations 1
• Triple therapy has demonstrated greater reduction in mortality compared to LABA/LAMA dual therapy in patients with high exacerbation risk 1
• For patients who remain symptomatic despite dual therapy like Advair (ICS/LABA), stepping up to triple therapy is recommended to improve symptoms and reduce exacerbation risk 1

Benefits of Triple Therapy (Trelegy)

• Triple therapy provides superior improvements in:

  • Lung function 1
  • Health-related quality of life 1
  • Dyspnea (breathlessness) 1
  • Reduction in moderate-severe exacerbations 1
  • Mortality reduction compared to dual bronchodilator therapy 1

• Trelegy offers the convenience of once-daily dosing in a single inhaler, which may improve adherence compared to using multiple inhalers 2

Patient Selection Considerations

• Triple therapy is particularly beneficial for patients with:

  • Moderate to very severe COPD (FEV1 <80% predicted) 1
  • Moderate to high symptom burden (CAT ≥10, mMRC ≥2) 1
  • History of exacerbations (≥2 moderate or ≥1 severe in the past year) 1
  • Blood eosinophil counts ≥300 cells/mL (stronger ICS response) 2

• For patients with concomitant conditions like emphysema and sarcoidosis who remain symptomatic on dual therapy, triple therapy offers comprehensive management of airway inflammation and bronchodilation 1

Administration and Dosing

• Trelegy (fluticasone furoate/umeclidinium/vilanterol) is administered as one inhalation once daily 3
• The patient should rinse their mouth with water without swallowing after inhalation to reduce the risk of oropharyngeal candidiasis 3
• Trelegy should be used at the same time every day and not more than once every 24 hours 3

Safety Considerations

• Common adverse events include headache and nasopharyngitis 4
• There is a slightly increased risk of pneumonia with ICS-containing regimens, but the benefit-risk ratio favors triple therapy in appropriate patients 2
• Regular monitoring for pneumonia is recommended, especially in patients with risk factors (current smokers, age ≥55 years, prior exacerbations/pneumonia, BMI <25 kg/m², severe airflow limitation) 2

Clinical Decision Algorithm

1. Assess current control:

   • If patient has persistent symptoms (mMRC ≥2) and/or exacerbations despite dual therapy 1
   • If FEV1 <80% predicted 1

2. Evaluate risk factors:

   • History of exacerbations (≥2 moderate or ≥1 severe in past year) 1
   • Blood eosinophil count (higher counts favor ICS-containing regimens) 2

3. Consider comorbidities:

   • For patients with emphysema and sarcoidosis, triple therapy addresses both airway inflammation and bronchodilation needs 1, 5

4. Initiate triple therapy:

   • Prescribe Trelegy (fluticasone furoate/umeclidinium/vilanterol) one inhalation daily 3
   • Ensure proper inhaler technique and adherence 3

5. Monitor response:

   • Assess symptom improvement, lung function, and exacerbation frequency 1
   • Watch for adverse effects, particularly pneumonia 2

Important Considerations for Sarcoidosis

• While triple therapy is primarily indicated for COPD management, the ICS component may provide additional benefit for the inflammatory component of sarcoidosis 5
• For patients with both emphysema and sarcoidosis, comprehensive management should address both conditions 5

Conclusion

Based on the most recent guidelines, triple therapy with Trelegy is the appropriate next step for patients with emphysema and sarcoidosis not adequately controlled on dual therapy such as Advair and albuterol. This approach offers the best chance of reducing mortality, improving symptoms, and preventing exacerbations 1.