Triple therapy for COPD has very different risk/benefits compared to asthma.

COPD management has significantly changed in the last decade, with inhaled corticosteroids no longer routinely prescribed, says Associate Professor Natasha Smallwood, head of the Chronic Respiratory Disease Research Group at Monash University.

“With asthma, we hand out inhaled corticosteroids really promptly, but with our patients with COPD, it has become the last step,” she says.

Associate Professor Smallwood says the first goal of treatment is to ensure the diagnosis is accurate.

Her next two priorities are improving symptoms and preventing exacerbation or deterioration.

“We want to slow disease progression, and we want to decrease mortality, if possible,” she says.

How do we define exacerbations? Associate Professor Smallwood says, “it’s not just day to day variations.” It’s a change in symptoms (cough, dyspnoea, sputum production), lasting at least seven to ten days, and requiring a change in management.

It’s also important to remember that exacerbations are not always infective. They may be caused by stress, air pollution, pulmonary embolism or even heart failure, a few of the examples Associate Professor Smallwood cites.

Treatment approaches

Non-pharmacological approaches to COPD management include smoking cessation, pulmonary rehabilitation programmes, and self-management techniques such as activity pacing or using a handheld fan.

“These techniques are actually quite evidence-based, so they actually do work,” Associate Professor Smallwood says. “The reason they fail is because patients don’t use them as much as we would like them to.”

While patients with minimal infrequent symptoms may get away with as-needed short acting bronchodilator reliever therapy alone, many patients will require some sort of maintenance pharmacotherapy.

The evidence favours long-acting muscarinic antagonist over long-acting beta agonist as maintenance therapy in the first instance, says Associate Professor Smallwood. Then they may be combined as dual therapy as the next step.

Combination LAMA/LABA is associated with a 20% decrease in exacerbations and an 11% decrease in hospitalisations, she says.

Triple therapy: when should and shouldn’t it be used

Patients with repeated exacerbations may be offered anti-inflammatory therapy in the form of inhaled corticosteroids added to their LAMA/LABA.

“Inhaled corticosteroids for COPD are now considered last line therapy, and we no longer prescribe them routinely,” Associate Professor Smallwood says.

Despite decreasing exacerbations, improving quality of life, and reducing all-cause mortality, triple therapy is not without potential adverse effects.

There is an increased risk of pneumonia, especially with fluticasone and for any steroid with increasing dose.

Avoid triple therapy in:

• Patients with repeated bouts of pneumonia
• Those with low eosinophil counts
• People with a history of mycobacterial infection.

Single combination devices may decrease the chance of patient errors, thereby maximising the effectiveness. They are also convenient and often improve adherence.

No one device or formulation has shown superiority over others, says Associate Professor Smallwood. Consider patient preference, cognition and manual dexterity when choosing.

While COPD is a chronic, progressive disease, there may be times to consider deprescribing.

“It is actually safe to step patients down, but we do have to do it with caution,” Associate Professor Smallwood says.

Patients on triple therapy with infrequent exacerbations and normal eosinophil count, without comorbid asthma may be considered for step down. When deprescribing, monitor carefully for change in symptoms, quality of life, lung function or frequency of exacerbation.

“COPD management is quite individualised these days,” Associate Professor Smallwood says. “It’s very different to the approach we take in asthma.”