A comparison of two triple-therapy combination inhalers for COPD

Triple therapy with an inhaled corticosteroid, a long-acting muscarinic antagonist, and a long-acting β-agonist is recommended for some patients with chronic obstructive pulmonary disease (COPD), but little is known about the comparative effectiveness of available triple-therapy combination inhalers. In addition, the adverse effect of pneumonia has been consistently shown in clinical trials and observational research of inhaled corticosteroids, but it is uncertain whether pneumonia risk differs in patients with COPD who receive budesonide-based rather than fluticasone-based regimens.To investigate these issues, a new US study compared the effectiveness and safety of budesonide–glycopyrronium–formoterol (Breztri Aerosphere), a twice-daily metered-dose inhaler, and fluticasone–umeclidinium–vilanterol (Trelegy Ellipta), a once-daily dry powder inhaler, in patients with COPD treated in routine clinical practice.The study used U.S. claims data over a 33-month period to identify patients (age ≥ 40 years) who were started on budesonide–glycopyrronium–formoterol or fluticasone–umeclidinium–vilanterol therapy for COPD. The main outcome measures in this 1:1 propensity score matched study were first moderate or severe COPD exacerbation (effectiveness) and first admission to hospital with pneumonia (safety) while on treatment. Potential confounders were measured in the one-year period before cohort entry and included in propensity scores.Results showed the following:The study cohort included 20,388 propensity score matched pairs of new users initiating single-inhaler triple therapy with twice-daily budesonide–glycopyrronium–formoterol metered-dose inhaler or once-daily fluticasone–umeclidinium–vilanterol dry powder inhaler.Patients who received budesonide–glycopyrronium–formoterol had a 9% higher incidence of first moderate or severe COPD exacerbation (hazard ratio [HR] 1.09; 95% confidence interval [CI] 1.04–1.14); number needed to harm = 38) compared with patients receiving fluticasone–umeclidinium–vilanterol.The risk of first moderate COPD exacerbation was 7% higher among those receiving budesonide–glycopyrronium–formoterol (HR 1.07; 95% CI 1.02–1.12); number needed to harm = 54).The risk of first severe COPD exacerbation was 29% higher among those receiving budesonide–glycopyrronium–formoterol (HR 1.29; 95% CI 1.12–1.48); number needed to harm = 97).Both triple therapies resulted in an identical incidence of first admission to hospital with pneumonia (HR 1.00; 95% CI 0.91–1.10). The authors conclude that twice-daily budesonide–glycopyrronium–formoterol metered-dose inhaler was not associated with improved clinical outcomes compared with once-daily fluticasone–umeclidinium–vilanterol dry power inhaler. Given the added climate impact of metered-dose inhalers, which contain hydrofluoroalkane propellants that contribute to greenhouse gas emissions, the authors advocate for prescribing of fluticasone–umeclidinium–vilanterol dry powder inhaler over budesonide–glycopyrronium–formoterol metered-dose inhaler in patients with COPD. The authors acknowledge, however, that dry powder inhalers may not be suitable for all patients with COPD. Reference:Feldman WB, Suissa S, Kesselheim AS, et al. Comparative effectiveness and safety of single inhaler triple therapies for chronic obstructive pulmonary disease: new user cohort study. Br Med J 2024;387:e080409. (accessed January 9, 2025).

A comparison of two triple-therapy combination inhalers for COPD

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