Different single inhaler triple therapies appear to have similar clinical outcomes for chronic obstructive pulmonary disease

1. In a cohort of adults with chronic obstructive pulmonary disease (COPD), receiving fluticasone-umeclidinium-vilanterol was not associated with improved clinical outcomes compared to receiving budesonide-glycopyrrolate-formoterol. 

Evidence Rating Level: 2 (Good) 

Treatment recommendations for chronic obstructive pulmonary disease (COPD) include triple inhaler combination therapy with an inhaled corticosteroid, a long-acting muscarinic antagonist, and a long acting β-agonist. In the United States, there are two single inhalers that incorporate the combination therapy. The two are budesonide-glycopyrrolate-formoterol (Breztri Aerosphere), a twice daily metered inhaler, and fluticasone-umeclidinium-vilanterol (Trelegy Ellipta), a once daily dry powder inhaler. Globally, health systems have tried to reduce the use of metered doses as they contain propellants which cause harm to the environment from greenhouse gas emissions. However, there have not been many studies comparing the two types of triple inhaler therapy. To address this gap, this study examined budesonide-glycopyrrolate-formoterol and fluticasone-umeclidinium-vilanterol to compare their effectiveness and safety in COPD patients. Eligibility criteria included having a diagnosis of COPD based on International Classification of Diseases, being ages 40 years or older, and being enrolled for at least one year before the study start time. Individuals were excluded if they had COPD but a previous asthma diagnosis. To address the effectiveness, the primary outcome was moderate or severe COPD exacerbation, and to address safety, the primary outcome was first admission to hospital with pneumonia. The study included 20 388 matched pairs from 87 751 individuals using fluticasone-umeclidinium-vilanterol, and 20 395 using budesonide-glycopyrrolate-formoterol. There was a 9% increased hazard of first moderate or severe COPD exacerbation in patients receiving budesonide-glycopyrrolate-formoterol compared to those receiving fluticasone-umeclidinium-vilanterol (HR 1.09 [95% CI 1.04 to 1.14]). When comparing the two treatment groups for pneumonia incidence, the hazard of first admission was the same (HR 1.00 [95% CI, 0.91 to 1.10]; absolute risk difference 0.4% [95% CI, -0.6% to 1.3%]). Looking at the results for the secondary outcome of all-cause mortality, there was a 7% increased relative hazard (HR 1.07 [95% CI 1.02 to 1.12]) and a 1.9% increase in absolute risk (95% CI 0.1% to 3.6%) in the budesonide-glycopyrrolate-formoterol group compared to the fluticasone-umeclidinium-vilanterol group. In summary, in a cohort of patients with COPD, those treated with fluticasone-umeclidinium-vilanterol did not experience better outcomes clinically than those treated with budesonide-glycopyrrolate-formoterol. However, health systems wanting to reduce their greenhouse gas emissions may recommend the use of fluticasone-umeclidinium-vilanterol as a safe and effective treatment.

Click to read the study in BMJ

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