In patients with chronic obstructive pulmonary disease (COPD) who have dyspnea and/or exercise intolerance, triple therapy is not superior to maintenance long-acting bronchodilator therapy, except in patients with a history of ≥1 exacerbations in the past year, according to study results published in the Annals of the American Thoracic Society.

In patients with COPD, inhaled corticosteroids (ICS) are often added to bronchodilator therapy to deliver anti-inflammatory medication directly to the site of inflammation. Although the addition of ICS maintenance therapy is expected to improve lung function, symptoms, quality of life, and hospitalizations, ICS monotherapy has not been shown to have definitive positive effects on mortality in COPD.

Therefore, researchers conducted a systematic review and meta-analyses of 11 studies (N=14,145 patients) to estimate the safety and efficacy of using triple therapy (ICS/long-acting β2-agonist [LABA]/long‐acting muscarinic antagonist [LAMA]) compared with LABA/LAMA dual therapy or monotherapy with a single long-acting bronchodilator in patients with COPD and dyspnea and/or exercise intolerance.

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The results revealed an increased risk of pneumonia (P <.001) and a decreased risk of acute exacerbations (AE) of COPD (P <.001) with triple therapy compared with treatment with dual and monotherapy long-acting bronchodilator therapy. In contrast, no significant difference in dyspnea scores (P =.06) or risk of hospitalization (P =.11) was noted. Triple therapy resulted in 230 fewer AEs of COPD and 16 more cases of pneumonia per 1000 patients in those with a history of ≥1AECOPD in the past year.

“Balancing the reduction in AECOPD frequency risk against the increased pneumonia frequency risk with the addition of ICS to dual therapy or monotherapy with long acting bronchodilators favored the use of triple therapy only in the subgroup with a higher baseline risk of COPD exacerbation risk, specifically individuals with ≥1 exacerbation(s) in the past year requiring antibiotics and/or oral steroids or hospitalization,” the study authors concluded.

Disclosure: Several clinical trials included in this study were supported by the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Mammen MJ, Lloyd DR, Kumar S, et al. Triple therapy versus dual or monotherapy with long-acting bronchodilators for COPD: a systematic review and meta-analysis.. Ann Am Thorac Soc. Published online July 21, 2020. doi:10.1513/AnnalsATS.202001-023OC