From 1st June 2018, a triple combination inhaler was added to the Pharmaceutical Benefits Scheme (PBS) for the treatment of chronic obstructive pulmonary disease (COPD). Trelegy® contains the corticosteroid fluticasone, the long-acting muscarinic antagonist (LAMA) umeclidinium, and the long-acting β2-agonist (LABA) vilanterol.

The IMPACT trial evaluated the efficacy of this combination in a single inhaler. The results demonstrated a 25% reduction in moderate to severe exacerbations and a 34% reduction in hospitalisations for triple therapy compared to the LAMA-LABA combination. However, patients in this study who were assigned to the LAMA-LABA group and had previously been taking an inhaled corticosteroid would have had their corticosteroid stopped abruptly. This could have contributed to the higher rate of exacerbations observed in this group.

The study authors conclude that further research using different trial designs is required to accurately evaluate the safety and efficacy of triple therapy in COPD. In the interim, the COPD-X guidelines recommend a stepwise approach for the management of COPD. A short-acting reliever can be used as needed with a LAMA or LABA added if necessary. Inhaled corticosteroids are only recommended for moderate to severe COPD as they are associated with an increased risk of pneumonia.

With the increasing variety of inhaler types available and research demonstrating that up to 90% of patients do not use their inhalers correctly, it is worth checking inhaler technique regularly. The National Asthma Council of Australia provides a range of instructional videos. PS Pharmacies can also provide an inhaler in-service with placebo devices upon request.

References:

  1. Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, Day NC, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med. 2018; 378(18): 1671-80.
  2. Trelegy® Ellipta® (fluticasone furoate/umeclidinium [as bromide]/vilanterol [as trifenatate]) Australian approved product information. Abbotsford: GlaxoSmithKline Australia. Approved 2017.

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