What inhaler contains a long-acting beta agonist (LABA), an inhaled corticosteroid (ICS), and a long-acting muscarinic antagonist (LAMA) for a patient with severe asthma or chronic obstructive pulmonary disease (COPD)?

Triple Therapy Inhalers for COPD and Severe Asthma

Several single-inhaler triple therapy (SITT) products containing LABA/LAMA/ICS are available, with the most studied being fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta) and beclometasone dipropionate/formoterol/glycopyrronium. 1, 2

Available Triple Therapy Combinations

The following fixed-dose triple combination inhalers contain all three components (LABA, LAMA, and ICS):

• Fluticasone furoate/vilanterol/umeclidinium - Once-daily dry powder inhaler licensed for moderate to severe COPD 1
• Beclometasone dipropionate/formoterol fumarate/glycopyrronium - Extrafine formulation evaluated in multiple clinical trials 2

Clinical Indications for Triple Therapy

Triple therapy is strongly recommended for patients with:

• High exacerbation risk (≥2 moderate exacerbations or ≥1 severe exacerbation requiring hospitalization in the past year) 3
• Moderate to high symptom burden (CAT ≥10 or mMRC ≥2) 3
• Impaired lung function (FEV1 <80% predicted) 3

Mortality and Morbidity Benefits

Triple therapy demonstrates superior outcomes compared to dual therapy:

• Reduces all-cause mortality compared to LABA/LAMA dual therapy (OR 0.70,95% CI 0.54-0.90) with moderate certainty of evidence 3, 4
• Decreases moderate-to-severe exacerbation rates by approximately 26% (rate ratio 0.74,95% CI 0.67-0.81) 4
• Improves health-related quality of life meeting the minimal clinically important difference threshold on SGRQ (OR 1.35,95% CI 1.26-1.45) 4

Important Clinical Considerations

Single-inhaler triple therapy (SITT) is preferred over multiple-inhaler combinations because evidence demonstrates incremental benefit with SITT compared to administering the same medications in separate devices 3

Blood eosinophil counts may guide therapy intensity:

• Patients with eosinophils ≥150-200 cells/µL show greater exacerbation reduction with triple therapy (RR 0.67) compared to those with lower eosinophil counts (RR 0.87) 4

Key Safety Caveat

Pneumonia risk increases with ICS-containing regimens (3.3% vs 1.9%, OR 1.74,95% CI 1.39-2.18), but the number needed to harm is 33 patients for 1 year to cause one pneumonia event, while the number needed to treat is only 4 patients for 1 year to prevent one moderate-to-severe exacerbation 3, 4

The risk-benefit ratio strongly favors triple therapy in appropriately selected high-risk patients, as the mortality reduction and exacerbation prevention benefits substantially outweigh the pneumonia risk 3, 2