David Halpin, MBBS, DPhil

Halpin reviews the state of triple therapy inhaler prescribing strategies in the era of new biologic options.

COPD Inhaler Use in the Biologic Era, with David Halpin, MBBS, DPhil

Single inhaler triple therapy options reached the US market in the last decade, providing clinicians a number of options to effectively treat the common symptoms of 

 without tasking a patient to adhere to multiple devices; options like fluticasone furoate / umeclidinium / vilanterol (Trelegy Ellipta)

 and budesonide / glycopyrrolate / formoterol (Breztrai Aerosphere)

 have simplified a patient’s means to receive a regular dose of inhaled corticosteroid (ICS), long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA).

But this drug class hasn’t come without its own practical hang-ups.

Chronic Obstructive Lung Disease (GOLD) International COPD Conference

 in Philadelphia, PA, this month, David Halpin, MBBS, DPhil, Clinical Lead of Respiratory Medicine at the University of Exeter, discussed the advantages and challenges alike that have emerged in the era of multiple-therapy inhaler devices to treat COPD.

While there are more opportunities to now fit a suitable device to a patient with COPD, the amplification of choices warrants an adequate understanding of each option.

“It's confusing for clinicians about how you should use them optimally,” Halpin said. “And so even though many devices are available, many clinicians default to a limited number that they're familiar with.”

There’s even differing methodology between single inhaler multiple therapy options — some warrant a twice-daily administration, others only one. Some do require an add-on treatment, others do not.

“Patients get very confused, and as a result, don't take it as well as they should and are more likely to have exacerbations and not get as good symptom control as they could achieve,” Halpin said. “There’s still a lot of work to do to educate the prescribers and to train the patients that having a single inhaler is much more convenient — patients are going to be more adherent and more likely to get the benefits from that treatment.”

Halpin also discussed general prescribing strategy trends in COPD. He noted that some of his colleagues may initiate a long-acting bronchodilator, wait to assess its benefit, then add a second bronchodilator, wait again, and finally add an ICS to a patient’s regimen. He stressed that this strategy is only delaying the time to optimal care — and time is everything in COPD treatment.

“The evidence suggests that if a patient needs the treatment, the sooner you start all of the components together, the better the outcomes will be,” he said.

The advent of biologic therapies to treat COPD further evidences the need to start timely, robust maintenance treatment as soon as the patient needs it; an add-on biologic is now available for most patients with severe cases.

“Biologics offer an opportunity to add on to the triple therapy, to further reduce those exacerbation rates,” Halpin said. “And they have to be tailored to the individual patient. But if you've got the right patients with the right biomarkers to indicate the need for a biologic, the biologics really offer something new.”

Walter K. FDA Approves COPD Triple Therapy. 

. Published July 24, 2020. https://www.hcplive.com/view/fda-approves-copd-triple-therapy

Hoffman M. FDA Grants New Indication to Trelegy Ellipta for COPD. 

. Published online April 24, 2018. https://www.hcplive.com/view/fda-grants-new-indication-to-trelegy-ellipta-for-copd

David Halpin, MBBS, DPhil

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