What are the alternatives to the Seebri (glycopyrronium) inhaler for a patient with chronic obstructive pulmonary disease (COPD)?

Alternatives to Seebri (Glycopyrronium) Inhaler for COPD

For patients currently using Seebri (glycopyrronium), the best alternative is tiotropium, another once-daily LAMA that provides equivalent 24-hour bronchodilation with comparable efficacy and safety, though with a slightly slower onset of action. 1

Direct LAMA Alternatives (Same Drug Class)

Tiotropium is the most established alternative LAMA with extensive evidence:

• Provides equivalent trough FEV1 improvements compared to glycopyrronium after 12 weeks of treatment 1
• Demonstrates comparable improvements in dyspnea (TDI scores), health status (SGRQ), rescue medication use, and exacerbation rates 1
• Has similar safety profile with 40.6% adverse event rate versus 40.4% for glycopyrronium 1
• Key difference: Slower onset of action on Day 1, with glycopyrronium showing significantly higher FEV1 at all time points 0-4 hours post-dose 1, 2

Umeclidinium is another once-daily LAMA option:

• Can be used as monotherapy for symptomatic COPD patients 3
• Available in combination formulations (umeclidinium/vilanterol) 4

Aclidinium is a twice-daily LAMA alternative:

• Indicated for maintenance bronchodilator treatment 5
• May be less convenient due to twice-daily dosing requirement 5

When to Consider Dual Bronchodilator Therapy

LAMA/LABA combinations should be considered if symptoms persist on LAMA monotherapy:

• The American College of Chest Physicians strongly recommends LAMA/LABA dual therapy over monotherapy for patients with moderate to severe dyspnea 6
• Available combinations include: umeclidinium/vilanterol, glycopyrronium/formoterol, glycopyrronium/indacaterol, and tiotropium/olodaterol 4, 5
• LAMA/LABA combinations provide superior efficacy without the pneumonia risk associated with ICS-containing regimens 7

When to Escalate to Triple Therapy

For patients with persistent exacerbations (≥2 per year or ≥1 hospitalization):

• Consider triple therapy with LAMA/LABA/ICS in a single inhaler 4, 6
• Options include fluticasone/umeclidinium/vilanterol (Trelegy Ellipta) or beclomethasone/glycopyrronium/formoterol 4
• Triple therapy significantly reduces mortality compared to LAMA/LABA in high-risk patients with FEV1 <80% predicted 6
• Important caveat: ICS-containing regimens increase pneumonia risk (NNH of 33 patients treated for one year) 4

Alternative Approach: LABA Monotherapy

Long-acting beta-agonists can be used as alternative monotherapy:

• Either LAMAs or LABAs are acceptable as first-line monotherapy based on patient preference, cost, and adverse effect profile 7, 3
• However, LAMAs are preferred because they demonstrate greater effect on exacerbation reduction and can decrease hospitalizations compared to LABAs 3
• LABA options include indacaterol, olodaterol, and vilanterol (though vilanterol is only available in combination) 5

Treatment Selection Algorithm

Step 1: Assess current symptom control and exacerbation history

• If well-controlled on glycopyrronium: Switch to tiotropium as direct equivalent 1
• If inadequate symptom control: Escalate to LAMA/LABA dual therapy 7, 6

Step 2: For patients with exacerbation history

• ≥2 exacerbations/year or ≥1 hospitalization: Consider LAMA/LABA or triple therapy 4
• Blood eosinophil count ≥150 cells/mm³: Consider ICS-containing regimen 4

Step 3: Consider patient-specific factors

• Cardiovascular comorbidities: Monitor carefully with LABA-containing medications 4
• Chronic bronchitis with FEV1 <50% predicted: Consider adding roflumilast if still experiencing exacerbations 7, 4
• Former smokers with persistent exacerbations: Consider adding macrolide therapy 7

Critical Pitfalls to Avoid

Never use ICS monotherapy - it is not recommended and should not be used 6

Ensure proper inhaler technique - 76% of patients make critical errors with metered-dose inhalers, so technique must be demonstrated before prescribing and rechecked periodically 6

Do not abruptly discontinue ICS in patients with asthma-COPD overlap, as this can lead to clinical deterioration 4

Avoid beta-blocking agents (including eyedrop formulations) in COPD patients 3

Reassess therapy effectiveness after switching medications - failing to do so is a common pitfall 4