LABA, LAMA and inhaled corticosteroid triple therapy for COPD

Consider adding an inhaled corticosteroid (ICS) to long-acting bronchodilator dual therapy if both of the following apply:

• the patient has had a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations in the previous 12 months, and
• the patient has significant symptoms despite dual therapy with a LAMA and LABA.

In a meta-analysis comparing triple therapy, LAMA monotherapy, LAMA plus LABA dual therapy, and ICS+LABA dual therapy, triple therapy improved lung function and quality of life, and reduced exacerbations, compared with other treatments. However, ICS are associated with an increased risk of pneumonia in patients with COPD. The benefits of adding ICS must be balanced against the increased risk of pneumonia and local adverse effects (dysphonia, upper airway candidiasis).

Response to oral corticosteroids does not predict response to ICS; do not use oral corticosteroids to identify which patients may benefit from ICS.

Triple therapy can be given as an ICS+LABA fixed-dose combination inhaler plus a separate LAMA inhaler, or as a single fixed-dose combination inhaler containing all three drug classes¹. There is no evidence that a single inhaler improves outcomes compared to separate inhalers. See Inhalers available in Australia for COPD for details of inhaled drug formulations for COPD, and Summary of inhalational drug delivery devices for information about devices.

For triple therapy with two separate inhalers², use:

For triple therapy with a single inhaler, use:

Assess response 3 to 6 months after starting treatment. Refer patients to a respiratory physician if they remain symptomatic or have continued exacerbations despite triple therapy.