Is Triple Therapy Better Than Two Bronchodilators In COPD?

No Difference in Shortness of Breath Scores or Risk of Hospitalization Compared with Two Bronchodilators

Background

“Triple therapy” refers to the use of three different inhaled medications – a long-acting beta-agonist (LABA), a long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid (ICS). “Two  bronchodilators” includes the combination of a LABA and LAMA.

The difference between these different combinations inhalers is the ICS. There is uncertainty on whether triple therapy provides greater benefit in those with COPD who complain of shortness of breath and/or have exercise limitation compared with two bronchodilators.

Study

Dr. Manoj Mammen and colleagues from the State University of New York of Buffalo as well as other institutions performed a systematic review of studies that compared results of triple therapy (3 medications) versus two bronchodilators in individuals with stable COPD who are affected by shortness of breath and/or limited in their activities. These authors searched the medical literature for studies from 1990 to June 2019 and then pooled results based on different outcomes. The study findings were published in the October 2020 issue of the Annals of the American Thoracic Society (volume 10; pages 1308-1318).

Manoj Mammen, MD

Associate Professor of Medicine, Jacobs School of Medicine

Results

Eleven studies were considered appropriate for analysis. There was no difference in shortness of breath scores or risk of hospitalization between triple therapy versus dual bronchodilator therapy.

With the combination of LABA, LAMA, and ICS, there was an increased risk of pneumonia and a decreased risk of a COPD flare-up (exacerbation) compared with two bronchodilators. For those with a history of one or more flare-ups of COPD in the past year, triple therapy resulted in 230 fewer flare-ups and 16 more cases of pneumonia per 1,000 patients.

Conclusions

Triple therapy was equal to two bronchodilators for relief of shortness of breath in those with COPD. In individuals with a history of one or more flare-ups in the past year, the benefits of triple therapy for reducing future flare-ups outweigh the increased risk of pneumonia.

My Comments

At the present time, there are two FDA approved “triple therapy” inhalers available in the United States: Breztri Aerosphere (a pressurized metered dose inhaler) and Trelegy Ellipta (a dry powder inhaler).

The findings of this systematic review and analysis are consistent with the recommendations of the GOLD Committee (global panel of COPD experts) that an ICS medication be used when a person with COPD is considered to be an increased risk of having a COPD flare-up. This is based on two or more flare-ups treated as an out-patient or one or more flare-ups requiring hospitalization in the past year.