For a patient with COPD and asthma who is taking Asmanex (mometasone), Trelegy (fluticasone furoate + umeclidinium + vilanterol), montelukast, and as‑needed albuterol, what medication change would best reduce symptoms?

Medication Optimization for COPD-Asthma Overlap

Primary Recommendation

Discontinue Asmanex (mometasone) immediately, as this patient is already receiving triple therapy with Trelegy (fluticasone furoate/umeclidinium/vilanterol) and the duplicate inhaled corticosteroid provides no additional benefit while increasing the risk of systemic corticosteroid side effects and pneumonia. 1

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Rationale for Eliminating Medication Duplication

The Core Problem: Redundant ICS Therapy

• This patient is receiving two separate inhaled corticosteroids: mometasone via Asmanex and fluticasone furoate via Trelegy, creating unnecessary duplication without evidence of added benefit 1, 2
• Trelegy already provides complete triple therapy (ICS/LAMA/LABA in a single inhaler), which is the guideline-recommended regimen for patients with moderate-to-severe COPD at high risk of exacerbations 1, 3
• Adding a second ICS increases pneumonia risk without improving lung function, symptoms, or exacerbation rates beyond what triple therapy alone provides 1

Why Trelegy Should Be Retained

• Single-inhaler triple therapy (SITT) is superior to multiple inhalers due to increased adherence, reduced technique errors, and proven mortality reduction in high-risk COPD patients 1, 4
• The 2023 Canadian Thoracic Society guidelines strongly recommend SITT for patients with moderate-to-severe disease at high risk of exacerbations (≥2 moderate or ≥1 severe exacerbation per year) 1
• Trelegy's once-daily dosing improves compliance compared to twice-daily regimens like Asmanex 3, 5

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Optimized Medication Regimen

Recommended Changes

1. STOP Asmanex (mometasone) – eliminates ICS duplication 1
2. CONTINUE Trelegy (fluticasone furoate/umeclidinium/vilanterol) once daily – provides complete triple therapy 1, 3, 4
3. CONTINUE montelukast – reasonable adjunct for asthma component, though evidence in COPD is limited 1
4. CONTINUE albuterol as needed – appropriate rescue therapy for all patients 1

Evidence Supporting This Approach

• Triple therapy with ICS/LAMA/LABA reduces moderate-to-severe exacerbations and significantly decreases mortality in high-risk COPD patients compared to dual therapy or monotherapy 1, 4
• The IMPACT trial demonstrated that umeclidinium/fluticasone furoate/vilanterol (Trelegy) was superior to dual therapies in reducing exacerbation rates, improving lung function (trough FEV₁), and enhancing quality of life 4
• Single-inhaler triple therapy is favored over multiple inhalers because of potential increased benefits, increased adherence, and reduced chance of errors in inhaler technique 1

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Addressing the Asthma Component

Role of Montelukast

• Montelukast is an appropriate alternative or adjunctive therapy for asthma, particularly in patients with mild persistent asthma or those unable to tolerate higher ICS doses 1
• Leukotriene modifiers have not been adequately tested in COPD, but given this patient's asthma-COPD overlap, continuing montelukast is reasonable 1
• The combination of ICS (via Trelegy) plus montelukast addresses both inflammatory pathways (corticosteroid-responsive and leukotriene-mediated) without duplication 1

Why Not Increase ICS Dose Further

• This patient is already on medium-to-high dose ICS via Trelegy (fluticasone furoate 100 mcg is roughly equivalent to fluticasone propionate 250 mcg) 3, 5
• Adding Asmanex on top of Trelegy does not provide step-up therapy; it simply duplicates the ICS component without the proven benefits of triple therapy 1
• If asthma symptoms remain uncontrolled after stopping Asmanex, consider adding a biologic (e.g., omalizumab for allergic asthma) rather than increasing ICS dose, per asthma guidelines 1

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Common Pitfalls to Avoid

Pitfall 1: Assuming More Inhalers Equals Better Control

• Multiple inhalers with overlapping drug classes increase side effects without improving outcomes 1
• Patients often use inhalers incorrectly when prescribed multiple devices, leading to poor adherence and suboptimal drug delivery 1

Pitfall 2: Treating COPD and Asthma as Separate Diseases

• Asthma-COPD overlap syndrome (ACOS) requires a unified approach, not separate regimens for each condition 1
• Triple therapy addresses both conditions: ICS for asthma inflammation, LAMA for COPD bronchodilation, and LABA for both 1, 4

Pitfall 3: Ignoring Pneumonia Risk with Dual ICS

• Regular ICS use increases pneumonia risk, especially in severe disease, and this risk is dose-dependent 1
• Eliminating the duplicate ICS reduces this risk while maintaining adequate anti-inflammatory therapy via Trelegy 1

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Monitoring After Medication Change

Short-Term (2–4 Weeks)

• Assess symptom control: dyspnea, cough, sputum production, and rescue inhaler use 1
• Evaluate for withdrawal symptoms: unlikely given continued ICS via Trelegy, but monitor for increased exacerbations 1

Long-Term (3–6 Months)

• Track exacerbation frequency: goal is ≤1 moderate exacerbation per year 1
• Monitor lung function: spirometry to assess FEV₁ stability 1, 4
• Assess quality of life: using validated tools like CAT (COPD Assessment Test) or ACQ (Asthma Control Questionnaire) 1, 4

Red Flags Requiring Escalation

• ≥2 moderate or ≥1 severe exacerbation despite triple therapy: consider adding roflumilast (PDE4 inhibitor) if chronic bronchitis is present, or long-term azithromycin if exacerbations persist 1
• Persistent eosinophilia (≥300 cells/μL): may benefit from biologic therapy (e.g., mepolizumab, benralizumab) for asthma component 1
• Worsening dyspnea despite optimal pharmacotherapy: refer for pulmonary rehabilitation, which is the best non-pharmacologic intervention for symptom relief 1, 6