Do you continue Duoneb (ipratropium and albuterol) with Yupelri (revefenacin) in patients with Chronic Obstructive Pulmonary Disease (COPD)?

Discontinue Duoneb When Starting Yupelri

You should discontinue Duoneb (ipratropium/albuterol) when initiating Yupelri (revefenacin) for maintenance COPD therapy, as both medications contain long-acting anticholinergics that should not be used concurrently. 1

Rationale for Discontinuation

Anticholinergic Duplication

• Yupelri is a long-acting muscarinic antagonist (LAMA) indicated for maintenance treatment of COPD 1
• The FDA label explicitly warns against using Yupelri with other anticholinergic medicines including ipratropium, as this creates therapeutic duplication and increases anticholinergic side effects 1
• Concurrent use of multiple anticholinergics increases risk of narrow-angle glaucoma, urinary retention, and other anticholinergic adverse effects 1

Superior Efficacy of Long-Acting Agents

• Long-acting muscarinic antagonists (such as revefenacin) are recommended over short-acting muscarinic antagonists (ipratropium) to prevent acute moderate to severe exacerbations of COPD, with a Grade 1A recommendation from the American College of Chest Physicians 2
• Patients previously maintained on ipratropium/albuterol combination taken four times daily can be switched to once-daily LAMA therapy with reasonable expectation of at least equivalent bronchodilation during daytime hours and superior bronchodilation during early morning hours 3

What to Continue: The Albuterol Component

Rescue Bronchodilator Therapy

• Continue short-acting beta-2 agonist (albuterol) as a rescue inhaler for acute symptom relief 1
• Yupelri is NOT meant to relieve acute symptoms of COPD, and patients must have access to an inhaled short-acting beta-2 agonist such as albuterol for breakthrough symptoms 1
• The albuterol component from Duoneb should be transitioned to a metered-dose inhaler or nebulizer solution for as-needed use only, not scheduled dosing 2

Clinical Implementation Algorithm

Step 1: Assess Current Symptom Control

• If patient requires Duoneb more than twice daily for symptom control, they are an appropriate candidate for maintenance LAMA therapy with Yupelri 4
• Document baseline FEV1, symptom scores, and exacerbation frequency before transition 3

Step 2: Initiate Yupelri and Discontinue Scheduled Duoneb

• Start Yupelri 175 mcg via nebulizer once daily at the same time each day 1
• Immediately discontinue all scheduled Duoneb doses to avoid anticholinergic duplication 1
• Provide albuterol 2.5 mg nebulizer solution or MDI for rescue use only (not scheduled) 2

Step 3: Patient Education on Medication Roles

• Educate patient that Yupelri is for daily maintenance, not acute relief 1
• Instruct patient to use albuterol rescue inhaler for sudden breathing problems 1
• Warn patient to seek immediate medical attention if rescue albuterol effectiveness decreases or if they need more inhalations than usual 1

Important Safety Caveats

Monitoring for Anticholinergic Effects

• Monitor for signs of narrow-angle glaucoma (eye pain, blurred vision, visual halos) especially in first weeks after transition 1
• Assess for urinary retention symptoms (difficulty passing urine, painful urination) particularly in patients with prostatic hyperplasia 1
• Use mouthpiece rather than face mask with nebulized Yupelri to minimize ocular exposure in patients at risk for glaucoma 2

Nebulizer Administration Specifics

• Yupelri should only be administered via standard jet nebulizer connected to air compressor with adequate airflow 1
• Do not mix Yupelri with other medications in the nebulizer 1
• In patients with CO2 retention, drive nebulizer with compressed air rather than oxygen to prevent worsening hypercapnia 2

When Combination Therapy May Still Be Needed

• If patient continues to have inadequate symptom control on Yupelri plus rescue albuterol alone, consider adding a long-acting beta-2 agonist (LABA) rather than restarting scheduled short-acting bronchodilators 4
• Triple therapy (LAMA + LABA + inhaled corticosteroid) is appropriate for patients with very severe COPD (GOLD category D) with frequent exacerbations 4