Current appraisal of single inhaler triple therapy in COPD

A single inhaler containing inhaled corticosteroid (ICS)/long acting beta-agonists (LABA)/long acting muscarinic antagonists (LAMA) is a more convenient way of delivering triple therapy in patients with COPD Single triple has been shown to be superior at reducing exacerbations and improving quality of life compared to LABA/LAMA especially in patients with a prior history of frequent exacerbations and blood eosinophilia, who have ICS responsive disease. The corollary is that patients with infrequent exacerbations who are non eosinophilic may be safely de-escalated from triple to LABA/LAMA without loss of control. Pointedly there is a substantially increased risk of pneumonia associated with the triple containing fluticasone furoate but not belcometasone dipropionate. Since triple is also better than ICS/LABA at reducing exacerbations and improving lung function, symptoms and quality of life, this brings into question the rationale for using ICS/LABA anymore. Hence we propose a simplified pragmatic decision process based on symptoms prior exacerbation history and blood eosinophils to select which patients should be given single triple or LABA/LAMA. Differences in patient preference inhaler devices formulations and drugs will also determine which triple inhaler prescribers elect to use.