When to use single-inhaler triple therapy in COPD: a practical approach for primary care health care professionals

Abstract

While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel's discussions. The survey confirmed the need to clarify the place of SITT in COPD management. The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year; 2) at least one severe exacerbation that required hospital admission in the previous year; 3) one exacerbation a year on a repeated basis for 2 consecutive years. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. Regular review is essential. During each review, HCPs should consider stepping treatment up or down. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. In this situation, the blood eosinophil count could aid decision making. ICSs should be continued when the history suggests that asthma overlaps with COPD. Training, counseling, and education should be individualized. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations; 2) where there is diagnostic uncertainty or suspected comorbidity; 3) whenever they feel "out of their depth." Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. Studies using real-world evidence need to confirm these benefits.

Keywords: guidelines; inhalers; maintenance therapy; routine care; treatment step-up.

Conflict of interest statement

Disclosure Dr S Gaduzo reports receiving consultancy fees for speaking at and chairing educational meetings and conferences on behalf of AstraZeneca, Boehringer Ingelheim, Chiesi Limited, GlaxoSmithKline, Pfizer, and Novartis. Dr V McGovern reports accepting speaker fees, advisory panel fees, and conference sponsorship from the following pharmaceutical companies: Altana, AstraZeneca, Almirall, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Merck Sharp & Dohme, NAPP, Novartis, Orion Pharma, and Pfizer. J Roberts reports receiving consultancy fees from AstraZeneca, Chiesi Limited, and GlaxoSmithKline. JE Scullion reports accepting honoraria or support from ADMIT, AstraZeneca, Boehringer Ingelheim, Mundipharma, Mylan, NAPP, Nutricia, Orion Pharma, Roche, Teva, Trudell Medical, and UKIG. Professor D Singh reports receiving sponsorship to attend and speak at international meetings, honoraria for lecturing or attending advisory boards, and research grants from AstraZeneca, Boehringer Ingelheim, Chiesi Limited, Genentech, GlaxoSmithKline, Glenmark, Johnson & Johnson, Merck, NAPP, Novartis, Pfizer, Skypharma, Takeda, Teva, Theravance, and Verona. The authors report no other conflicts of interest in this work.

Figures

Figure 1

Routes to the instigation of triple therapy in patients with COPD. Abbreviations: LABA, long-acting beta2-agonist; LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroid.

Figure 2

Factors that influence the choice of pharmacological treatment for COPD. Notes: n=266 except for “other” where n=7. In your opinion, how important are the following factors in making a choice around which pharmacological COPD treatment should be prescribed? 1 denotes most important and 9 least important. Values for mean score: 1–3= high importance, 4–6= medium importance, 7–9= low importance.

Figure 3

Higher blood eosinophil counts predict a better response to ICS. Abbreviation: ICS, inhaled corticosteroid.