What to know about triple therapy for COPD

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Triple therapy combines three types of medication to help improve lung function, manage symptoms, and prevent exacerbations. It delivers these medications through an inhaler, which provides relief from swelling in the lungs and opens the airways so that the person can breathe. An example of a triple therapy for COPD is Trelegy Ellipta.

Triple therapy combines long-acting bronchodilators and inhaled steroids, so it will include the following:

• Inhaled corticosteroid (ICS): These drugs help reduce inflammation in the airways.
• Long-acting beta agonist (LABA): These are long-acting bronchodilators that help relax muscles around the airways to keep them open.
• Long-acting muscarinic agonist (LAMA): These are another type of long-acting bronchodilator that helps relax the muscles to keep the airways open.

Triple therapy is typically an effective treatment for people with advanced or severe COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) will usually recommend triple therapy for people who experience recurrent exacerbations despite using other forms of treatment for COPD, such as dual therapy with LABA and LAMA.

Typically, a doctor will first suggest another treatment, such as dual therapy, before escalating to triple therapy if the initial treatment proves ineffective. Although it is not common practice, some researchers propose that it may be beneficial to consider triple therapy as a first-line treatment in specific, very severe cases of COPD.

With proper use, triple therapy can help effectively control COPD symptoms and possible complications. A 2018 review notes that triple therapy can help lower the rate of moderate or severe flare-ups, improve lung function, and provide a better health-related quality of life for people with COPD.

The triple therapy approach may also make it easier for a person to take their medication, as it provides three medications in a single dose. This may make it more likely that the person will use their medication each day, helping the treatment work as intended.

However, this may not always be the case. A 2020 study found that 85% of people taking triple therapy missed at least 20% of their doses. The researchers note that this may be because people feel as though the medicine is not doing anything unless they are having an exacerbation of symptoms.

Dual therapy is another form of combination therapy for COPD. It combines two types of drugs into one inhaler. Some versions may combine both long-acting bronchodilators, while others may use just one and combine it with an ICS.

A doctor may recommend that a person with COPD start with dual therapy if they experience persistent symptoms or exacerbations. Then may then consider escalating to triple therapy if dual therapy is not effective for controlling symptoms or exacerbations.

Most evidence suggests that triple therapy is effective in helping severe cases of COPD but that it may not be necessary for milder cases, especially if dual therapy is helping manage symptoms. A 2019 meta-analysis found that there was an association between triple therapy and reduced moderate-to-severe COPD exacerbations compared with dual therapy. A reduction in exacerbations may also make hospitalization less likely.

A separate review from 2018 found that people who had triple therapy had a lower risk of moderate-to-severe COPD exacerbations, better lung function, and a higher quality of life compared with those who had either dual therapy — using an ICS and LABA or a LABA and LAMA — or monotherapy using a LAMA. This finding is consistent with a 2019 study, which adds that triple therapy is more effective in managing COPD for people with frequent exacerbations.

The results from clinical trials in 2018 and 2020 investigating triple therapy treatments for COPD note that in addition to effectiveness, the safety and tolerability of triple therapy are comparable to those of dual therapies.

However, triple therapy does carry its own risks. A 2018 article highlights that triple therapy may increase the risk of pneumonia compared with other therapies.

A 2020 systematic review identified some limitations as to when triple therapy is best. Based on the 11 included studies, the authors suggest that triple therapy is only better for certain groups of people, such as those who have had more than one COPD exacerbation in the past year and complain of trouble breathing or exercising.

Typically, people will start on another form of treatment, such as dual therapy, to try to control their symptoms. If it is ineffective, a doctor may then suggest triple therapy. Triple therapy may occasionally be suitable as a first-line treatment for people who have had two or more moderate-to-severe exacerbations of COPD symptoms in the past year. However, this is not standard practice.

Even in these groups, doctors will want to administer additional tests and discuss the possible side effects of triple therapy with their patients.

All medications can potentially cause side effects. The side effects of triple therapy may be similar to those of the medications themselves. They may include:

• headaches
• cough
• diarrhea
• back pain and joint pain
• changes in the sense of taste

These medications may also increase the risk of some other complications, such as:

• pneumonia
• oral thrush, or candidiasis infections
• immunosuppression, increasing the risk of other conditions
• weakened bones
• issues in the eye, such as glaucoma

Various factors may affect the risk, including the type of individual medications in the triple therapy and a person’s medical history and overall health. A person should always discuss all options with a doctor before moving forward with triple therapy.

Triple therapy aims to control COPD symptoms by combining common and effective medications into one single-dose inhaler. It may be best for people with severe COPD who experience recurrent exacerbations and those unable to control COPD symptoms with single or dual therapy options.

Although triple therapy is typically effective, it carries its own risks, such as the increased risk of pneumonia. It is advisable for a person to speak with their doctor about the benefits and possible risks of triple therapy. The doctor can help determine whether the person could benefit from triple therapy and provide other options to treat COPD symptoms if necessary.