Current appraisal of single inhaler triple therapy in COPD

Abstract

A single inhaler containing inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA) is a more convenient way of delivering triple therapy in patients with COPD. Single triple therapy has been shown to be superior at reducing exacerbations and improving quality of life compared to LABA/LAMA, especially in patients with a prior history of frequent exacerbations and blood eosinophilia, who have ICS responsive disease. The corollary is that patients with infrequent exacerbations who are noneosinophilic may be safely de-escalated from triple therapy to LABA/LAMA without loss of control. Pointedly, there is a substantially increased risk of pneumonia associated with the triple therapy containing fluticasone furoate but not beclometasone dipropionate or budesonide. Since triple therapy is also better than ICS/LABA at reducing exacerbations and improving lung function, symptoms, and quality of life, this brings into question the rationale for using ICS/LABA. Hence, we propose a simplified pragmatic decision process based on symptoms, prior to exacerbation history, and blood eosinophils to select which patients should be given a single triple inhaler or LABA/LAMA. Differences in patient preference of inhaler device, formulations and drugs will also determine which triple inhaler prescribers elect to use.

Weathering the Cytokine Storm in Susceptible Patients with Severe SARS-CoV-2 Infection

“…Patients with COPD taking inhaled corticosteroid (ICS) combination therapy have an increased pneumonia risk, especially with lipophilic drugs such as fluticasone furoate, 11 due to its prolonged lung retention and associated local immunosuppression in the presence of altered lung microbiome and impaired mucociliary clearance. 12 Moreover, suppression of interferon by fluticasone propionate is associated with an increased bacterial load after rhinovirus infection. 13 Corticosteroids may also attenuate production of the antibacterial protective peptide cathelicidin in the lung epithelium.…”

<p>Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms</p>

“…The concept of switching to ICS with lower risk of side-effects (SE) is based on data which demonstrated substantially increased risk of pneumonia with using of more potent and lipophilic ICS such as fluticasone propionate or fluticasone furoate, but not beclometasone dipropionate or budesonide 73,74. It is possible that the differences observed in the incidence of pneumonia reflect the dose of ICS used.…”

Withdrawal of inhaled corticosteroids in patients with chronic obstructive pulmonary disease

“…Концепция перехода на иГКС с меньшим риском НЯ основана на данных, которые продемонстрировали существенно повышенный риск развития пневмонии при использовании более липофильных иГКС, таких как флутиказона пропионат или флутиказона фуроат, но не беклометазона дипропионат или будесонид [66,67]. Возможно, что наблюдаемые различия в заболеваемости пневмонией отражают используемую дозу иГКС.…”

“…Таким образом, у пациентов с ХОБЛ с анамнезом обострений и / или повышенным риском пневмонии и / или инфекционных обострений целесообразно заменить иГКС на молекулы с более низким риском НЯ, например, флутиказон -на будесонид или беклометазон [67,68].…”