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The randomised controlled trial (GLISTEN) by Frith et al1 showed significant improvements in trough FEV1, health-related quality of life and rescue medication when long-acting muscarinic antagonists (LAMA: as either tiotropium or glycopyrronium) were added to inhaled corticosteroid/long-acting beta-agonist (ICS/LABA: as fluticasone/salmeterol) in 773 patients with moderate-to-severe COPD (FEV1 57.2%) over 12 weeks. The authors concluded that this was the first study, which conclusively demonstrates the benefits of triple therapy compared with dual therapy. In a retrospective cohort study using health informatics reported by Short et al,2 2853 patients with moderate-to-severe COPD were followed up over 4.65 years; of whom, 996 were receiving ICS/LABA (FEV1 62.7%) and 1857 receiving ICS/LABA/LAMA (FEV1 50.8%). Comparing outcomes using triple versus dual therapy, the adjusted HRs were 0.85 (95% CI 0.73 to 0.99) for hospital admissions, 0.71 (95% CI 0.63 to 0.80) for oral corticosteroid bursts and 0.74 (95% CI 0.63 to 0.88) for all-cause mortality. Serial FEV1 measurements over 4 years fell by 30 mL (95% CI 10 to 60 mL) in the triple therapy group. This, in turn, indicates the putative long-term clinically relevant benefits by adding LAMA to ICS/LABA in a real-life setting, especially where adherence rates are likely to be lower using two separate inhalers in comparison with what might occur in a medium-term randomised controlled trial. Hence, there may be long-term potential benefits conferred by the use of single-inhaler triple therapy when used in real life for patients with more severe COPD.
Competing interests BL has received support to attend BTS and ERS from Boehringer Ingelheim and has also received payment for attending advisory boards from Boehringer Ingelheim, Chiesi and Teva. The Scottish Centre for Respiratory Research has received unrestricted education grant funding from Almirall, Teva and Chiesi. Scottish Centre for Respiratory Research has received support to attend ERS from Teva and Chiesi.
Provenance and peer review Not commissioned; internally peer reviewed.
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