Medication Optimization for Severe COPD-Asthma Overlap
Discontinue Asmanex (mometasone furoate) immediately, as this patient is already receiving adequate inhaled corticosteroid therapy through Trelegy and the duplication provides no additional benefit while increasing pneumonia risk and systemic corticosteroid adverse effects. 1
Rationale for Discontinuing Asmanex
The current regimen contains redundant ICS therapy that violates evidence-based prescribing principles:
- Trelegy already contains fluticasone furoate (an ICS) combined with umeclidinium (LAMA) and vilanterol (LABA), providing complete triple therapy 2
- Adding Asmanex exposes the patient to two different ICS medications simultaneously, which is not supported by any guideline recommendations 1
- ICS-containing regimens carry a number needed to harm of 33 patients treated for one year to cause one pneumonia case 1, 3
- Systemic adverse effects from ICS increase with cumulative exposure, including a 4% increased pneumonia risk compared to non-ICS regimens 1
Optimizing the Current Regimen
After discontinuing Asmanex, the patient should continue:
- Trelegy (fluticasone furoate/umeclidinium/vilanterol) as the cornerstone triple therapy, which improves lung function, symptoms, health status, and reduces exacerbations compared to dual therapy 4, 2
- Montelukast may be continued given the asthma-COPD overlap, though evidence in pure COPD is limited 4
- Albuterol as needed for rescue therapy 2
Evidence Supporting Triple Therapy in COPD-Asthma Overlap
Triple therapy is specifically recommended for patients with concomitant asthma and COPD:
- The 2023 Canadian Thoracic Society guidelines state that ICS/LABA combination therapy is preferred to LAMA/LABA dual therapy in individuals with COPD and concomitant asthma (strong recommendation) 4
- Triple therapy (LAMA/LABA/ICS) provides moderate to high certainty of greater improvements in dyspnea and health status compared to LAMA/LABA dual therapy or ICS/LABA combination therapy 4
- In the IMPACT trial, Trelegy reduced the annual rate of moderate/severe exacerbations by 15% compared with fluticasone furoate/vilanterol and by 25% compared with umeclidinium/vilanterol 2
Additional Considerations if Symptoms Persist
If the patient remains symptomatic after discontinuing Asmanex:
- For chronic bronchitis phenotype with FEV₁ <50% predicted and continued exacerbations, add roflumilast (a PDE4 inhibitor) rather than additional ICS 4, 1
- Roflumilast improves lung function and reduces moderate and severe exacerbations in patients with chronic bronchitis, severe to very severe COPD, and exacerbation history 4
- Evaluate for pulmonary rehabilitation, which combined with optimal pharmacotherapy represents the best option to alleviate dyspnea and improve health status 4
- Consider long-term azithromycin (250 mg daily or 500 mg three times weekly) if exacerbations persist, though this increases bacterial resistance and hearing impairment risk 4
Critical Pitfall to Avoid
Never attempt to "boost" ICS therapy by adding Pulmicort, Asmanex, or any other ICS to Trelegy, as this represents irrational polypharmacy without evidence of benefit. 1 When patients have persistent symptoms despite triple therapy, the solution is adding non-ICS medications (like roflumilast), optimizing inhaler technique, addressing comorbidities, or initiating pulmonary rehabilitation—not duplicating corticosteroid therapy 4, 1.