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Triple therapy (ICS/LABA/LAMA) in COPD: time for a reappraisal

Journal article
Authors Lowie E G W Vanfleteren
Leonardo M. Fabbri
A. Papi
S. Petruzzelli
B. Celli
Published in International Journal of Chronic Obstructive Pulmonary Disease
Volume 13
Pages 3971-3981
ISSN 1178-2005
Publication year 2018
Published at Institute of Medicine
Pages 3971-3981
Language en
Links dx.doi.org/10.2147/copd.S185975
Keywords muscarinic antagonists, adrenergic beta(2) receptor agonists, glucocorticoids, pulmonary disease, chronic obstructive, review, exacerbations, safety, obstructive pulmonary-disease, double-blind, inhaled corticosteroids, fluticasone propionate/salmeterol, parallel-group, bronchodilator, therapy, cardiovascular events, airway inflammation, beta-agonists, tiotropium, Respiratory System, uri m, 2018, am j resp crit care, v197
Subject categories Respiratory Medicine and Allergy

Abstract

Recently, two "fixed triple" single-inhaler combinations of an inhaled corticosteroid (ICS), a long-acting beta(2)-agonist (LABA), and a long-acting muscarinic antagonist (LAMA) have become available for patients with COPD. This review presents the clinical evidence that led to the approval of these triple therapies, discusses the role of ICS in patients with COPD, and presents data on the relative efficacy of "fixed triple" (ICS/LAMA/LABA) therapy vs LAMA, ICS/LABA, and LAMA/LABA combinations, and summarizes studies in which ICS/LABAs were combined with LAMAs to form "open triple" combinations. Of the five main fixed triple studies completed so far, three evaluated the efficacy and safety of an extrafine formulation of beclometasone dipropionate, formoterol fumarate, and glycopyrronium; the other two studies evaluated fluticasone furoate, vilanterol, and umeclidinium. Overall, compared to LAMA, ICS/LABA, or LAMA/LABA, triple therapy decreased the risk of exacerbations and improved lung function and health status, with a favorable benefit-to-harm ratio. Furthermore, triple therapy showed a promising signal in terms of improved survival. The evidence suggests that triple therapy is the most effective treatment in moderate/severe symptomatic patients with COPD at risk of exacerbations, with marginal if any risk of side effects including pneumonia. Ongoing studies are examining the role of triple therapy in less severe symptomatic patients with COPD and asthma-COPD overlap.

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