A stepwise approach to the treatment of patients with chronic obstructive pulmonary disease is recommended. Triple therapy may have a role in this approach for some patients.
Guidelines for treating chronic obstructive pulmonary disease (COPD) generally suggest that combination therapy with dual bronchodilators plus inhaled corticosteroids (ICS) should be reserved for patients with a forced expiratory volume in one second (FEV1) of less than 50% predicted and repeated exacerbations.1,2 Australian PBS guidance stipulates the same conditions. In reality, many patients with COPD are using triple therapy, without necessarily a clear indication. Similarly, in studies from the UK it was found that about 50% of patients with COPD were receiving triple therapy within three years of initial diagnosis.3 A percentage of these individuals will have coexistent asthma (so-called ‘asthma-COPD overlap’), but many will neither have frequent exacerbations nor features of asthma. How should these patients be managed? Who requires triple therapy?