![]() ![]() Two single-inhaler triple therapy (SITT) devices are now available in the UK: Trimbow (extra-fine formulation of beclometasone dipropionate plus formoterol fumarate dihydrate plus glycopyrronium ) and Trelegy Ellipta (fluticasone furoate plus vilanterol trifenatate plus umeclidinium bromide ). Historically, triple therapy has been prescribed with two separate inhalers, namely an ICS plus LABA inhaler and a LAMA inhaler. Routes to the instigation of triple therapy in patients with COPD.Ībbreviations: LABA, long-acting beta 2-agonist LAMA, long-acting muscarinic antagonist ICS, inhaled corticosteroid. 5 Mortality appears to be up to five times higher after the 10th severe exacerbation compared with that following the first hospitalization for COPD. 5, 7 – 9 Daily mortality, for instance, peaks at 40 per 10,000 of the population in the first week after admission for a severe exacerbation. 6 Moreover, exacerbations account for about 25% of the decline in lung function, increase the risk of mortality and hospital admissions, and reduce HRQoL in people with COPD. For example, the risk of myocardial infarction was 2.27-fold higher 1–5 days after a COPD exacerbation and the risk of stroke was 1.26-fold higher between 1 and 49 days later. ![]() 3 COPD is characterized by a progressive deterioration in lung function over many years, punctuated by periodic exacerbations, 5 which drive much of the morbidity and mortality associated with COPD. 4 Partly driven by demographic changes, COPD mortality is rising. Moreover, COPD is predominately a disease of older people. 3 However, other causes of mortality have shown a greater decline. 1 Age- and sex-specific mortality from COPD has declined in recent years. 2ĭespite a decrease in the number of people who smoke, COPD represented 5.3% of the total mortality in the UK in 2012. 1 The intangible costs arising from excess mortality and reduced health-related quality of life (HRQoL) in people with COPD far exceed the direct costs to health services and indirect costs associated with, for example, lost productivity. Studies using real-world evidence need to confirm these benefits.Īccording to the British Lung Foundation, ~1.2 million people have been diagnosed with COPD in the UK. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations 2) where there is diagnostic uncertainty or suspected comorbidity 3) whenever they feel “out of their depth.” Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. ![]() Training, counseling, and education should be individualized. ICSs should be continued when the history suggests that asthma overlaps with COPD. In this situation, the blood eosinophil count could aid decision making. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. During each review, HCPs should consider stepping treatment up or down. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. ![]() The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year 2) at least one severe exacerbation that required hospital admission in the previous year 3) one exacerbation a year on a repeated basis for 2 consecutive years. The survey confirmed the need to clarify the place of SITT in COPD management. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel’s discussions. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. ![]()
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