Next Step Up from Spiriva (Tiotropium)
The next step up from Spiriva is adding a LABA/ICS combination (such as fluticasone/vilanterol or fluticasone/salmeterol) to your existing tiotropium therapy, creating triple therapy with a LAMA + LABA + ICS. 1
Rationale for Triple Therapy
Adding a LABA/ICS combination to tiotropium (rather than switching medications) provides superior outcomes for patients with moderate to severe COPD who remain symptomatic on LAMA monotherapy:
Triple therapy (LAMA + LABA/ICS) reduces severe exacerbations and improves symptoms in patients with moderate or severe COPD compared to LAMA alone 1
The LABA/ICS combination improves health-related quality of life and reduces the risk of moderate or severe COPD exacerbations when added to existing therapy 1
This stepwise approach maintains the proven benefits of tiotropium while addressing residual symptoms and exacerbation risk 1
Evidence Supporting This Approach
The guideline evidence strongly supports adding rather than switching:
LAMAs (like tiotropium) have demonstrated superiority over LABAs alone in reducing COPD exacerbations, exacerbation-related hospitalizations, and adverse effects 1
When LABA/ICS was directly compared to LAMA alone, they were equivalent for exacerbation prevention, with some outcomes favoring the LABA/ICS combination 1
The combination of all three medication classes provides additive benefits that exceed what can be achieved with dual therapy 1
Alternative Dual Bronchodilator Option
If inhaled corticosteroids are contraindicated or not desired (e.g., due to pneumonia risk), consider adding a LABA alone to create LAMA/LABA dual bronchodilation:
LABA/LAMA combinations increase lung function to a greater degree than LAMA alone 1
Tiotropium-olodaterol is one such fixed-dose combination that has demonstrated efficacy in improving FEV₁, dyspnea, hyperinflation markers, and quality of life beyond the minimal clinically important difference 2
This approach avoids the increased pneumonia risk associated with inhaled corticosteroids 1
Important Caveats
Pneumonia risk: The LABA/ICS combination carries an increased risk of pneumonia, though this effect may vary among different formulations 1. This risk must be weighed against the benefits of exacerbation reduction.
Patient phenotype matters: Patients with a history of chronic bronchitis and frequent exacerbations (≥2 per year) respond better to preventative therapy 1. The optimal regimen may differ based on exacerbation history and eosinophilic phenotype.
Adherence considerations: All recommended therapies should be accompanied by short-acting bronchodilators (SABDs) for as-needed use 3. Long-acting medications like tiotropium and LABA/ICS combinations require scheduled daily use, not PRN administration 3.