What alternative inhaler can be prescribed for a patient who is intolerant to Incruse (umeclidinium) due to recurrent oral thrush and lip sores, despite proper rinsing and previous treatment with Nystatin, and has previously tried tiotropium without adequate effect?

From the Guidelines

I strongly recommend switching the patient from Incruse (umeclidinium) to a combination of a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA), such as Anoro Ellipta (umeclidinium and vilanterol), as this combination has been shown to improve lung function, symptoms, and health status, and reduce exacerbations in patients with COPD 1. For the oral thrush, continue nystatin oral suspension 4-5 mL swish and swallow four times daily for 7-14 days. The patient should also use a spacer with their inhaler, rinse their mouth thoroughly after each use, and consider using a chlorhexidine mouthwash to help clear the infection. Some key points to consider when making this switch include:

• The patient's history of trying tiotropium without good effect, but the different delivery system of Spiriva Respimat or the combination of LABA and LAMA may be better tolerated.
• The potential benefits of adding an inhaled corticosteroid (ICS) to the treatment regimen, but also the increased risk of pneumonia associated with ICS use, particularly in patients with severe disease 1.
• The importance of monitoring the patient's response to the new treatment regimen and adjusting as needed to minimize side effects and optimize outcomes.
• The patient's symptoms, such as lip sores and red tongue, should be closely monitored and addressed promptly to improve their quality of life. It is also important to note that the patient's underlying respiratory condition and medical history should be taken into account when making any changes to their treatment regimen, and consultation with a pulmonologist may be necessary to determine the best course of treatment. The use of a LABA and LAMA combination, such as Anoro Ellipta, is supported by the GOLD executive summary, which recommends this combination for patients with COPD who have a history of exacerbations and moderate to very severe disease 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for COPD

The patient is experiencing thrush and lip sores due to Incruse use and is seeking alternative treatment options. Considering the patient's history with tiotropium and Incruse, the following alternatives can be explored:

• Umeclidinium/vilanterol (UMEC/VI) combination therapy, which has shown to be effective in improving lung function and reducing symptoms in patients with COPD 2, 3
• Tiotropium/olodaterol (TIO/OLO) combination therapy, which has been compared to UMEC/VI in a randomized study, showing similar safety profiles but differing efficacy 2
• Adding umeclidinium to inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) therapy, which has demonstrated benefits in patients with symptomatic COPD 4

Efficacy and Safety of Alternative Treatments

Studies have shown that:

• UMEC/VI combination therapy is well-tolerated, safe, and non-inferior or better than other currently available inhaled fixed-dose LAMA/LABA combinations for COPD 3
• TIO/OLO combination therapy has a similar safety profile to UMEC/VI, but may have differing efficacy 2
• Adding umeclidinium to ICS/LABA therapy improves lung function and reduces symptoms in patients with symptomatic COPD 4

Considerations for Treatment Selection

When selecting an alternative treatment, consider the patient's:

• Medical history, including previous responses to tiotropium and Incruse
• Current symptoms and lung function
• Potential side effects and interactions with other medications
• Preferences and ability to adhere to the treatment regimen 5, 6