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Is triple therapy for COPD more effective than dual therapy?

By Nicole MacKee
Patients with severe chronic obstructive pulmonary disease (COPD) who are managed with triple therapy – an inhaled corticosteroid (ICS), a long-acting beta-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) – have fewer exacerbations than those on dual therapies, say researchers in The New England Journal of Medicine.

Leading Australian respiratory physician, Professor Christine Jenkins, Head of the Respiratory Group at The George Institute for Global Health, Sydney, welcomed the findings from the randomised Informing the Pathway of COPD Treatment (IMPACT) trial and said they were in line with other randomised controlled trials. However, she cautioned that the results were not generalisable to all patients.

‘This trial recruited patients with the most severe diseases; there is a much wider spectrum of patients with COPD in primary care,’ Professor Jenkins told Medicine Today.

The year-long industry-sponsored trial included 10,355 patients with forced expiratory volume in one second (FEV1) less than 50% of the predicted value and a history of at least one moderate or severe exacerbation in the past year, or an FEV1 of 50 to 80% predicted and at least two moderate exacerbations or one severe exacerbation in the previous year.

They were randomised to receive triple therapy (fluticasone furoate 100mcg, umeclidinium 62.5mcg and vilanterol 25mcg) or dual therapy with either an ICS-LABA (fluticasone furoate-vilanterol) or a LAMA-LABA (umecladinium-vilanterol) combination. All regimens were delivered once daily in a single Ellipta inhaler.

Patients in the triple therapy group experienced fewer moderate or severe exacerbations, with a rate of 0.91 per year, compared with 1.07 per year in the ICS-LABA group and 1.21 in the LAMA-LABA group. Hospitalisations were also lower in the triple therapy group than in the LABA-LAMA group.

Professor Jenkins said patients in both ICS-containing groups had about double the rates of pneumonia and lower respiratory tract infection as patients in the LAMA-LABA group.

‘Patients who are not frequently exacerbating and whose FEV1 is better than 50% predicted may do equally well on LABA-LAMA and not have adverse effects,’ she said, adding that the IMPACT findings supported the recommendations in Australia’s recently updated COPD-X Guidelines.

Professor Jenkins said she hoped these findings, together with the recently announced increase in the spirometry general practice rebate from 1 November 2018, would encourage more GPs to assess lung function before prescribing therapies for COPD. ‘Treatment decisions should be based on FEV1, not just symptoms and exacerbation history,’ she said.
N Engl J Med 2018; doi: 10.1056/NEJMoa1713901.