What is the proper use and dosage of Trelegy Ellipta (fluticasone furoate, umeclidinium, and vilanterol) for an adult patient with chronic obstructive pulmonary disease (COPD) or asthma?

Trelegy Ellipta: Proper Use and Dosing for COPD

Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol) should be administered as one inhalation once daily for maintenance treatment in adults with moderate to severe COPD who remain inadequately controlled on dual therapy with an inhaled corticosteroid plus long-acting beta-agonist. 1

Patient Selection Criteria

Trelegy Ellipta is specifically indicated for patients with moderate to severe COPD who have not achieved adequate symptom control with ICS/LABA combination therapy alone. 1 This aligns with the broader principle that treatment escalation in COPD should follow a stepwise approach based on disease severity and exacerbation history 2.

• The medication is particularly appropriate for patients with severe COPD and repeated exacerbations, where adding triple therapy (ICS + LABA + LAMA) has demonstrated improved symptom scores and health status beyond dual therapy 3
• Consider this option when patients on dual ICS/LABA therapy continue to experience inadequate symptom relief or frequent exacerbations 1

Dosing Regimen

The standard dose is one inhalation once daily, delivering fluticasone furoate 100 mcg, umeclidinium 62.5 mcg, and vilanterol 25 mcg per actuation. 1

• Administer at the same time each day for optimal consistency 1
• The once-daily dosing regimen is strongly preferred by patients compared to twice-daily alternatives, which may improve adherence 4
• No dose adjustments are specified in the available evidence for different severities of COPD 1

Proper Inhaler Technique

Correct use of the ELLIPTA dry powder inhaler is achieved by approximately 80% of patients, with most rating it as "easy" or "very easy" to use. 5

Key steps for proper administration:

• Open the cover fully until you hear a click, which loads the dose 5
• Breathe out fully away from the inhaler 5
• Place the mouthpiece between your lips and breathe in steadily and deeply 5
• Remove the inhaler and hold your breath for about 3-4 seconds 5
• Close the cover after use 5

Critical pitfall to avoid: Ensure patients receive proper training on inhaler technique at initiation, as technique errors are common in COPD and can lead to poor disease management 5. The ELLIPTA device demonstrates consistent dose delivery across a wide range of inspiratory flow rates (41.6-136.9 L/min), making it suitable for patients with varying disease severity 6.

Device-Specific Advantages

The ELLIPTA inhaler offers several attributes that patients prefer over older devices:

• Larger, easier-to-read dose counter numbers 4
• Fewer steps required for administration 4
• More comfortable mouthpiece design 4
• Simpler opening mechanism 4
• Once-daily dosing versus twice-daily alternatives 4

Clinical Context and Treatment Algorithm

Before initiating Trelegy Ellipta, confirm that patients have tried and failed dual ICS/LABA therapy, as triple therapy represents an escalation step in COPD management. 1

The treatment hierarchy for COPD should follow this general approach:

• Mild symptomatic COPD: Short-acting bronchodilators as needed 2
• Moderate COPD: Single long-acting bronchodilator (LABA or LAMA) 2
• Severe COPD with exacerbations: Dual therapy (ICS/LABA or LABA/LAMA) 2
• Severe COPD inadequately controlled on dual therapy: Triple therapy with Trelegy Ellipta 1

Patients with severe COPD and repeated exacerbations despite dual therapy are the ideal candidates for triple therapy escalation. 3

Monitoring and Follow-Up

Regular assessment should include symptom relief, inhaler technique verification, FEV1 measurements, and exacerbation frequency. 2

• Verify proper inhaler technique at each visit, as this is a common source of treatment failure 5
• Assess for objective improvement in lung function (FEV1 increase ≥200 mL and ≥15% from baseline) to justify continued therapy 2
• Monitor for side effects typical of ICS therapy, including oral candidiasis and pneumonia risk 2

Safety Considerations

Avoid beta-blockers (including ophthalmic formulations) in all patients receiving Trelegy Ellipta, as they can antagonize the beta-agonist component. 2

• The safety profile in clinical studies showed adverse events in approximately 13% of patients using ELLIPTA devices, with most being mild 4
• Serious adverse events were rare and generally not device-related 4