Support for stepwise approach to COPD

Triple therapy should not be necessary for most patients with COPD but the concern about overprescription remains.

Dr Eli Dabscheck, a respiratory physician at the Alfred Hospital, Melbourne, and co-chair of the national COPD-X guidelines committee, said evidence that inhaled corticosteroids (ICS) were already overprescribed supported those concerns.

Speaking at the Respiratory Insights Forum in Melbourne, he said ICS were clearly not being reserved for patients with a FEV1 less than 50% predicted and repeated exacerbations.

Instead local research has shown significant discordance between guideline recommendations and ICS use in COPD.

A Melbourne study of more than 700 patients found 72% of patients were on an ICS including 52.4% of all patients with a post-bronchodilator FEV1 ≥ 50%1.

Dr Dabscheck said the IMPACT study2 had shown a lower rate of exacerbations with triple therapy compared to dual therapy – either ICS/LABA or LAMA/LABA – independent of the patients’ eosinophil counts.

In addition the study had found all-cause mortality was lower with both the regimens that included an inhaled corticosteroid.

However he noted the 50% higher rate of pneumonia with triple therapy than with the LAMA/LABA combination.

He referred to a NEJM editorial which stated that, given the high rate of ICS use in patients at IMPACT’s baseline, those who were randomised to LAMA/LABA would in effect be stepping down from therapy . The abrupt withdrawal of ICS may explain the surge in exacerbations in the LAMA/LABA group in the first month after randomisation. Exacerbation rates with LAMA/LABA were then similar to those with triple therapy for next 11 months3.

Dr Dabscheck said the SUNSET study showed that patients were often on more medication than was necessary.

“These are the patients we see – those that come in on every inhaler possible.”

The study showed that de-escalation of ICS from long-term triple therapy was possible in low-risk COPD patients with no more than one exacerbation in the previous year4.

It also showed that ICS withdrawal did not have an impact on moderate or severe exacerbations,

with the exception of patients with high blood eosinophil counts (≥300 cells/μL).

Dr Dabscheck said he strongly recommended sticking to the stepwise management guidelines for COPD which included considering interventions such as pulmonary rehabilitation and vaccines as well managing cardiac comorbidities, anxiety and depression.

“I think we need a more systematic approach to assessing the COPD patient which doesn’t just focus on which inhaler is right. The guidelines make a lot of good suggestions; I just don’t know if day-to-day, we are able to apply it with sufficient time and precision,” he told the limbic.

“It has started to happen in asthma with great effort and cost and time involved, but I haven’t seen it translate to a systematic approach in COPD.”


  1. Harrison A et al. Inappropriate inhaled corticosteroid prescribing in chronic obstructive pulmonary disease patients. Int Med J. 2017:47(11):1310-13.
  2. Lipson DA et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med. 2018;378:1671-80
  3. Suissa S & Drazen JM. Making Sense of Triple Inhaled Therapy for COPD. N Engl J Med. 2018;378:1723-24.
  4. Chapman KE et al. Long-term Triple Therapy De-escalation to Indacaterol/Glycopyrronium in COPD Patients (SUNSET): a Randomized, Double-Blind, Triple-Dummy Clinical Trial. AJRCCM. 2018. In press.

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