The use of a single inhaler that contains triple therapy in patients with chronic obstructive pulmonary disease (COPD) can lower the rate of moderate or severe exacerbations compared with the use of long-acting β2-agonist (LABA)/long-acting muscarinic receptor antagonist (LAMA) or inhaled corticosteroid (ICS)/LABA dual therapy.
The results of a systematic review and meta-analysis of randomized controlled trials (RCTs) were published in the International Journal of Chronic Obstructive Pulmonary Disease.
Investigators sought to compare the effects of single inhaler triple therapy containing ICSs, LABAs, and LAMAs with dual therapies containing either LABA/LAMA, ICS/LABA, or separate ICS/LABA plus LAMA triple therapy. They performed a literature search through October 31, 2018, to identify clinical studies that were relevant to the topic. Only RCTs were included in the meta-analysis. The primary study outcome was the rate of moderate to severe COPD exacerbations.
Overall, 7 studies fulfilled the inclusion criteria. Single inhaler triple therapy was shown to be associated with a significantly lower risk for COPD exacerbations compared with LABA/LAMA (rate ratio, 0.69; 95% CI, 0.55- 0.87; I2=85%) and ICS/LABA (rate ratio, 0.81; 95% CI, 0.73-0.89; I2=29%) dual therapy. The use of single inhaler triple therapy resulted in a more significant improvement in lung function and quality of life compared with the use of LABA/LAMA and ICS/LABA dual therapy. However, the use of single inhaler triple therapy compared with the use of LABA/LAMA was associated with a higher risk for pneumonia (risk ratio, 1.38; 95% CI, 1.14-1.67; I2=0).
A major strength of the analysis was that only RCTs with a low risk for bias were included. In addition, all of the studies evaluated were published in the last 3 years. A major limitation, however, is that although most of the studies enrolled only patients with a forced expiratory volume in 1 second of <50% and a prior history of COPD exacerbations, some of the studies did not. Moreover, the patients who were included in the analysis used different LAMAs/LABAs and ICSs from various devices and in different dosing regimens.
The investigators concluded that even though the use of single inhaler triple therapy in patients with COPD was associated with lower rates of disease exacerbations, and improved lung function and quality of life, compared with LABA/LAMA or ICS/LABA dual therapy, triple therapy did not reduce overall mortality rates. Also, the route of administration of triple therapy (eg, single vs separate inhalers) did not appear to affect outcomes in patients with COPD.
Lai C-C, Chen C-H, Lin CYH, Wang C-Y, Wang Y-H. The effects of single inhaler triple therapy vs single inhaler dual therapy or separate triple therapy for the management of chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis. 2019;14:1539-1548.