Can Incruse (umeclidinium) replace Yupelri (revefenacin) in the management of Chronic Obstructive Pulmonary Disease (COPD)?

Can Incruse Replace Yupelri?

Yes, Incruse (umeclidinium) can replace Yupelri (revefenacin) for COPD maintenance therapy, but the decision depends primarily on the patient's ability to use a dry powder inhaler versus requiring nebulized delivery. Both are long-acting muscarinic antagonists (LAMAs) with similar mechanisms of action and efficacy profiles, but they differ fundamentally in their delivery systems.

Key Considerations for Replacement

Delivery Device Requirements

• Yupelri (revefenacin) is the only LAMA approved for once-daily nebulized delivery via standard jet nebulizer, making it specifically designed for patients who prefer or require nebulized therapy 1.

• Incruse (umeclidinium) is delivered via dry powder inhaler, requiring adequate inspiratory flow and hand-breath coordination 1.

• Nebulized delivery is preferable in patients who are elderly, cognitively impaired, unable to generate sufficient inspiratory force, have difficulty with hand-breath coordination, are too dyspneic to hold their breath adequately, or are acutely ill 2.

Efficacy Comparison

Both agents demonstrate:

• Significant improvements in trough FEV1 compared to placebo in patients with moderate to very severe COPD 2, 3.

• Sustained bronchodilation over 24 hours with once-daily dosing 2, 4.

• Improvements in patient-reported outcomes including SGRQ, TDI, and dyspnea scores 3, 4.

• Maintained therapeutic effect over 52 weeks with revefenacin showing trough FEV1 improvements ranging from 52.3-124.3 mL 4.

Clinical Scenarios for Replacement

You can confidently switch from Yupelri to Incruse if:

• The patient demonstrates adequate inhaler technique with dry powder devices 5.
• The patient has sufficient inspiratory flow capacity 2.
• The patient prefers a portable inhaler over nebulizer setup 1.
• Cost or insurance coverage favors the dry powder formulation.

You should NOT replace Yupelri with Incruse if:

• The patient requires nebulized therapy due to severe dyspnea or inability to use handheld inhalers 2.
• The patient is elderly with cognitive impairment affecting device use 2.
• The patient is combining multiple nebulized therapies (LABA, ICS) and benefits from consolidated nebulizer sessions 1.
• The patient has demonstrated poor technique or adherence with dry powder inhalers previously 5.

Safety Profile

• Both agents show good tolerability with low incidence of systemic antimuscarinic adverse events 2.
• No evidence of increased cardiovascular risk with either agent 2.
• Revefenacin was specifically designed with lung selectivity to minimize systemic effects 2.

Practical Algorithm

1. Assess inhaler technique capability: Can the patient generate adequate inspiratory flow and coordinate actuation? If yes, Incruse is appropriate. If no, maintain Yupelri 5, 2.

2. Evaluate concurrent nebulized therapies: Is the patient using nebulized LABA or ICS? If yes, keeping all therapies nebulized may improve adherence 1.

3. Consider patient preference: Does the patient prefer portability of dry powder inhaler versus home nebulizer setup? 1.

4. Verify disease severity: Both work in moderate to very severe COPD, including patients with severe airflow obstruction (FEV1 30-<50% predicted) 3.

Important Caveats

• Inhaler technique must be optimized and verified before any switch from nebulized to dry powder delivery 5.

• Beta-blocking agents (including eye drops) should be avoided in all COPD patients regardless of which LAMA is used 5.

• The combination of LAMA with LABA provides additive benefit in severe disease, and this can be achieved with either delivery system 5.

• Patients with very severe COPD (FEV1 <30% predicted) may benefit from maintaining nebulized therapy due to ease of use during acute worsening 3.