Combining Advair Diskus and Stiolto for COPD
No, a patient should not be on both Advair Diskus (ICS/LABA) and Stiolto (LAMA/LABA) together, as this creates inappropriate duplication of LABA therapy and does not align with evidence-based COPD treatment algorithms.
Why This Combination is Problematic
The regimen duplicates LABA therapy (salmeterol in Advair + olodaterol in Stiolto), which provides no additional benefit and increases the risk of LABA-related adverse effects including tremor, tachycardia, and hypokalemia 1.
The appropriate evidence-based regimen depends on the patient's exacerbation risk:
For Low Exacerbation Risk Patients
If the patient has ≤1 moderate exacerbation in the past year without hospitalization:
LAMA/LABA dual therapy alone is the recommended initial maintenance therapy for patients with moderate-to-high symptom burden (CAT ≥10, mMRC ≥2) and impaired lung function (FEV₁ <80% predicted) 1.
LAMA/LABA dual therapy is preferred over ICS/LABA because it provides significant improvement in lung function with lower rates of pneumonia 1.
The Canadian Thoracic Society strongly recommends against ICS-containing regimens in low-risk patients, as the pneumonia risk (number needed to harm = 33 patients for 1 year) is not justified when exacerbation risk is low 2.
Appropriate regimen: Switch to Stiolto (LAMA/LABA) alone and discontinue Advair 1.
For High Exacerbation Risk Patients
If the patient has ≥2 moderate exacerbations or ≥1 severe exacerbation (requiring hospitalization/ED visit) in the past year:
LAMA/LABA/ICS triple therapy in a single inhaler is strongly recommended with moderate certainty of evidence for reducing mortality and exacerbations 1, 2.
Triple therapy demonstrates a number needed to treat of 4 patients for 1 year to prevent one moderate-to-severe exacerbation 2.
Single-inhaler triple therapy is preferred over multiple inhalers due to improved adherence and reduced errors in inhaler technique 2.
Appropriate regimen: Switch to a single-inhaler triple therapy product (such as Trelegy Ellipta containing fluticasone/umeclidinium/vilanterol) and discontinue both Advair and Stiolto 1, 2, 3.
Clinical Reasoning
The current combination of Advair (fluticasone/salmeterol) plus Stiolto (tiotropium/olodaterol) creates a regimen of LAMA + LABA + LABA + ICS, which is not a recognized treatment strategy in any COPD guideline 1.
While one pilot study suggested potential benefits of combining fluticasone/salmeterol with tiotropium in severe COPD, this was before modern triple therapy formulations existed and did not include the additional LABA found in Stiolto 4.
Important Caveats
Exception for COPD-asthma overlap: ICS/LABA combination therapy is preferred to LAMA/LABA in patients who have COPD with concomitant asthma, but this would still not justify adding Stiolto on top of Advair 1.
Stepping down from triple therapy is not recommended for high-risk patients, particularly those with blood eosinophil counts ≥300 cells/µL, as withdrawing ICS may increase exacerbation risk 1, 2.
Monitor for pneumonia risk when using ICS-containing regimens, as this is the primary adverse effect that must be balanced against exacerbation reduction benefits 1, 2.