Clarify the Role of Combo Inhalers for COPD

More combo “LABA/LAMA” inhalers (Anoro, Stiolto, etc) will be used to treat COPD...due to updated guidelines.

Evaluate symptoms and exacerbation history to guide initial med choice.

Continue to start with a long-acting beta-agonist (Serevent, etc) OR long-acting muscarinic antagonist (Spiriva, etc) for patients with minor symptoms (occasional breathlessness, etc).

But jump to a COMBO inhaler with a LABA/LAMA for patients with more persistent or severe symptoms...or more than 1 exacerbation or a COPD hospitalization in the last year.

Prior guidelines suggested a LABA or LAMA for many of these patients...but using a combo LABA/LAMA earlier can reduce exacerbations.

Choose a LABA/LAMA combo based on patient preference, payer coverage, etc. All combo products are effective and cost at least $450/month...generally less than 2 separate inhalers.

Ensure all patients with COPD also get a short-acting bronchodilator (albuterol, etc) prn to relieve symptoms.

We know that inhaled corticosteroids (ICS) aren’t for everyone...and are linked to pneumonia and thrush. Consider blood eosinophil levels to help identify patients more likely to benefit from inhaled steroids.

For example, inhaled steroids may decrease exacerbations if eosinophils are about 300 cells/µL or above...but may not have benefit if below 100 cells/µL.

Generally save “triple therapy,” or adding an inhaled steroid to a LABA/LAMA combo, for patients with severe symptoms or exacerbations...with eosinophils of about 100 cells/µL or above.

Watch for patients with COPD using a LABA/ICS combo (Advair, etc)...and evaluate if a switch to a LABA/LAMA or triple therapy is needed.

Reserve roflumilast (Daliresp) or long-term azithromycin for patients with persistent exacerbations despite max therapy.

Continue to assess adherence...reinforce proper inhaler technique...update vaccinations (flu, COVID-19, pneumococcal, etc)...and emphasize smoking or vaping cessation if needed.

Use our resource, Improving COPD Care, to sort through meds.

Key References

  • (2-27-23)
  • Respir Res. 2019 Oct 30;20(1):238
  • Medication pricing by Elsevier, accessed Feb 2023

Prescriber's Letter. March 2023, No. 390311

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