Next Best Inhaler After Breo Ellipta
For COPD patients requiring escalation beyond Breo Ellipta (ICS/LABA dual therapy), the next best option is Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol) - a single-inhaler triple therapy that adds a long-acting muscarinic antagonist to your current regimen. 1, 2
When to Escalate to Triple Therapy
You should move to triple therapy if your patient meets any of these criteria while on Breo:
- Persistent moderate to severe dyspnea despite dual therapy 1, 2
- High exacerbation risk: ≥2 exacerbations per year OR ≥1 hospitalization for COPD 1, 3
- Severe airflow obstruction (FEV₁ <50% predicted) with frequent exacerbations 3
- Poor health status despite optimized dual therapy 2
The Canadian Thoracic Society and American Thoracic Society both recommend single inhaler triple therapy (SITT) for these patients, noting it may reduce mortality in individuals with moderate-severe disease compared to dual therapy options 1, 2.
Why Trelegy is the Logical Next Step
Device continuity matters clinically: Trelegy uses the same Ellipta inhaler device as Breo, eliminating the learning curve and technique errors that occur when switching device types 1. This is a significant practical advantage - patients already familiar with the Ellipta device can transition seamlessly without retraining 4.
Once-daily dosing is maintained: Both Breo and Trelegy are administered once daily, preserving the adherence advantage your patient already has 1, 5.
Alternative Option: Anoro Ellipta (LAMA/LABA)
If your patient doesn't need inhaled corticosteroid therapy (no frequent exacerbations, primarily dyspnea-driven symptoms), consider Anoro Ellipta (umeclidinium/vilanterol 62.5/25 mcg) - a LAMA/LABA combination without ICS 6, 7.
Anoro is superior to Breo for:
- Patients where ICS risks (pneumonia, systemic effects) outweigh benefits 3
- Those with primarily obstructive symptoms without inflammatory exacerbation phenotype 6
- Patients experiencing ICS-related adverse effects on Breo 8
Anoro demonstrated significantly greater pulmonary function improvement than tiotropium monotherapy and salmeterol/fluticasone propionate in head-to-head trials 6. It also uses the Ellipta device, maintaining device familiarity 6, 7.
Critical Pitfall to Avoid
Never add Pulmicort or any other separate ICS to Trelegy - this represents irrational polypharmacy with increased pneumonia risk (number needed to harm of 33 patients treated for one year) without guideline support 3. When transitioning from Breo to Trelegy, discontinue Breo completely rather than continuing both 3.
If Triple Therapy Proves Insufficient
For patients with chronic bronchitis phenotype and FEV₁ <50% predicted still experiencing exacerbations on Trelegy, add roflumilast rather than duplicating ICS therapy 3. Also evaluate for pulmonary rehabilitation, oxygen therapy, or treatment of comorbidities 3.
Evidence Quality Note
The combination therapy recommendations come from multiple high-quality guidelines including the Global Initiative for Chronic Obstructive Lung Disease (GOLD), Canadian Thoracic Society, American Thoracic Society, and European Respiratory Society 8, 1, 2, 3. However, a Cochrane review noted that the relative efficacy and safety of combination inhalers remains somewhat uncertain due to missing outcome data in current studies 8. Despite this limitation, the mortality benefit signal seen with triple therapy in moderate-severe disease supports escalation in appropriate patients 1, 2.