Is the combination of Breo Ellipta (fluticasone furoate/vilanterol) and Anoro Ellipta (umeclidinium/vilanterol) with Combivent Respimat (ipratropium bromide/albuterol) reasonable for a patient with Chronic Obstructive Pulmonary Disease (COPD) exacerbation and pneumonia, and should Combivent Respimat be continued upon discharge?

From the Guidelines

The combination of Breo Ellipta, Anoro Ellipta, and Combivent Respimat is not recommended due to therapeutic duplication, and Combivent Respimat should not be continued on discharge. The patient is already receiving two medications containing long-acting bronchodilators: Breo Ellipta provides an inhaled corticosteroid (fluticasone) plus a long-acting beta-agonist (LABA, vilanterol), while Anoro Ellipta provides a long-acting muscarinic antagonist (LAMA, umeclidinium) plus the same LABA (vilanterol) 1. Adding Combivent Respimat introduces duplication of both anticholinergic therapy (ipratropium overlaps with umeclidinium) and beta-agonist therapy (albuterol overlaps with vilanterol). During hospitalization for acute exacerbation, short-term use of Combivent may be reasonable for breakthrough symptoms, but continuing it at discharge would result in therapeutic duplication and increased risk of side effects like tachycardia, tremor, dry mouth, and urinary retention.

Some key points to consider in the management of COPD exacerbations include:

• The use of short-acting bronchodilators for rescue therapy, as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1
• The potential benefits of combination therapy with inhaled corticosteroids and long-acting beta-agonists, as well as long-acting muscarinic antagonists, in reducing exacerbations and improving lung function 1
• The importance of considering the risk of pneumonia and other adverse effects when using inhaled corticosteroids, particularly in patients with a history of pneumonia or other risk factors 1

Instead, a short-acting beta-agonist like albuterol alone would be more appropriate for rescue therapy upon discharge, avoiding the anticholinergic duplication while providing as-needed symptom relief. This approach is supported by the American College of Chest Physicians and Canadian Thoracic Society guideline, which recommends the use of short-acting bronchodilators for rescue therapy in patients with COPD 1. Additionally, the GOLD executive summary recommends the use of short-acting beta-agonists as the initial bronchodilator for acute exacerbations of COPD 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Combination of Puffers

• The patient is currently on long-term Breo Ellipta (fluticasone furoate/vilanterol) and Anoro Ellipta (umeclidinium/vilanterol), which are both used for the maintenance treatment of COPD.
• The addition of Combivent Respimat (ipratropium bromide/albuterol) for pneumonia and COPD exacerbation is a common practice, as it provides an additional bronchodilator effect.
• According to the studies, the combination of a LAMA (umeclidinium), a LABA (vilanterol), and an ICS (fluticasone furoate) is a recommended treatment for severe COPD patients who remain symptomatic and/or have frequent exacerbations despite dual therapies 2, 3.

Continuation of Combivent Respimat on Discharge

• The decision to continue Combivent Respimat on discharge should be based on the patient's response to the treatment and the severity of their COPD.
• Studies have shown that prompt initiation of single-inhaler triple therapy (SITT) with fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) following an exacerbation results in improved clinical outcomes for patients with COPD 4.
• However, there is no direct evidence to suggest that Combivent Respimat should be continued on discharge. The treatment plan should be individualized based on the patient's needs and response to treatment.
• It is essential to consider the patient's overall treatment plan, including their current medications and any potential interactions or side effects, when deciding whether to continue Combivent Respimat on discharge 5, 6.