Triple Treatment Reduces COPD Exacerbations- NEJM
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Triple fixed-dose regimens of an inhaled glucocorticoid, a long-acting muscarinic antagonist (LAMA), and a long-acting beta 2 agonist (LABA) for chronic obstructive pulmonary disease (COPD) have been studied at single dose levels of inhaled glucocorticoid, but studies at two dose levels are lacking.

In a 52-week, phase 3, randomized trial to evaluate the efficacy and safety of triple therapy at two dose levels of inhaled glucocorticoid in patients with moderate-to-very-severe COPD and at least one exacerbation in the past year, we assigned patients in a 1:1:1:1 ratio to receive twice-daily inhaled doses of triple therapy (inhaled glucocorticoid, a LAMA, and a LABA) or one of two dual therapies (18 µg of glycopyrrolate plus 9.6 µg of formoterol or 320 µg of budesonide plus 9.6 µg of formoterol). The primary end point was the annual rate (the estimated mean number per patient per year) of moderate or severe COPD exacerbations, as analyzed in the modified intention-to-treat population with the use of on-treatment data only.

Results: The modified intention-to-treat population comprised 8509 patients. The annual rates of moderate or severe exacerbations were 1.08 in the 320 µg budesonide triple-therapy group, 1.07 in the 160 µg budesonide triple-therapy group, 1.42 in the glycopyrrolate–formoterol group, and 1.24 in the budesonide–formoterol group.

The rate was significantly lower with 320 g budesonide triple therapy than with glycopyrrolate–formoterol or budesonide–formoterol. Similarly, the rate was significantly lower with 160 µg budesonide triple therapy than with glycopyrrolate–formoterol or budesonide–formoterol. The incidence of any adverse event was similar across the treatment groups; the incidence of confirmed pneumonia ranged from 3.5 to 4.5% in the groups that included inhaled glucocorticoid use and was 2.3% in the glycopyrrolate–formoterol group.

Conclusively, Triple therapy with twice-daily budesonide (at either the 160 µg or 320 µg dose), glycopyrrolate, and formoterol resulted in a lower rate of moderate or severe COPD exacerbations than glycopyrrolate–formoterol or budesonide–formoterol.

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1916046
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