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 FDA Drug Label

After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. The patient is already rinsing well after use and has a refill of Nystatin, but still experiencing thrush and lip sores.

• Alternative inhaler options should be considered for the patient, as they are not tolerating Incruse and have tried tiotropium without good effect.
• Salmeterol (INH), such as Wixela Inhub, may be an option, but the patient's response to this medication is unknown 1.
• The patient's lip sores and red tongue should be monitored and treated accordingly.

From the Research

I strongly recommend switching the patient from Incruse (umeclidinium) to Tudorza (aclidinium) as an alternative long-acting muscarinic antagonist (LAMA) due to the patient's history of oral thrush and lip sores despite proper rinsing technique, and previous ineffective trial of tiotropium. The patient should continue using nystatin for the current thrush infection until resolved. To prevent recurrence, they should rinse their mouth thoroughly after each inhaler use, gargle with water, and spit it out. Consider adding a spacer device if the inhaler is compatible. Some key points to consider in this decision include:

• The most recent and highest quality study 2 compared umeclidinium/vilanterol with fluticasone propionate/salmeterol, budesonide/formoterol, and tiotropium as initial maintenance therapy in patients with COPD who have high costs and comorbidities, and found that umeclidinium/vilanterol had lower COPD-related medical costs and exacerbation risk.
• However, given the patient's specific situation and previous ineffective trial of tiotropium, Tudorza (aclidinium) may be a better option.
• The patient's thrush is likely due to local immunosuppression from inhaled medications, which creates an environment for Candida overgrowth. If thrush persists with the new inhaler, consider evaluating for other causes of immunosuppression or adding a prophylactic antifungal mouth rinse to their regimen.
• The patient should follow up in 2-4 weeks to assess response to the new medication and resolution of oral symptoms.