Maximizing Dual Bronchodilators for COPD Patient’s Benefit
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Chronic Obstructive Pulmonary Disease is a common lung disease that is characterized by the presence of airway limitation. Global Initiative for Chronic Obstructive Lung Disease (GOLD) has been used as a strategy for healthcare professionals worldwide to structure their assessment and create treatment plans on COPD patients. GOLD 2019 introduces the blood eosinophil count for estimating the efficacy of Inhaled Corticosteroid (ICS) for the prevention of exacerbations1. In the follow up treatment, prescription of patients with persistent dyspnea who are using monotherapy are recommended to be escalated to dual therapy. If symptoms are not improved, stepping down to monotherapy and switching inhaler device or molecule should be considered. For patients with persistence dyspnea switching LABA/ICS to LABA/LAMA should be considered if the indication of ICS was inappropriate, or ICS response is lacking, or if ICS side effect occurs. For patients with persistence exacerbations who are prescribed monotherapy, escalation to LABA/LAMA or LABA/ICS can be considered. LABA/ICS is preferred for patients with history of asthma, or patients with blood eosinophil count ≥300 cells/μL or patients with ≥ moderate to severe exacerbations/year and blood eosinophil count ≥ 100 cells/μL. Patients with persistence exacerbations who use LABA/LAMA can be prescribed LABA/ICS if blood eosinophil count ≥ 100 cells/μL. If not, addition of roflumilast or azithromycin should be considered. Prescription of LABA/LAMA/ICS for patients with persistence exacerbation should be considered to be deescalated to LABA/LAMA if adverse event related to ICS occurs. ICS is often inappropriately prescribed for COPD patients, usually in fixed dose combination with Long Acting β2 Agonist (LABA)2. Following GOLD 2019, these prescriptions should be considered. Several researches regarding the switch from LABA/ICS to LABA/LAMA have been conducted. In the POWER study3, the FEV1 of patients with moderate-to-severe COPD improved by 175 mL at week 16 after switch to fixed dose combination of Indacaterol/Glycopyrronium (IND/GLY). The improvement was 176 mL (95% CI: 135-217) following a direct change from tiotropium and 172 mL (95% CI: 85-258) following a direct change from fixed dose combination of Salmeterol Fluticasone (SFC). Patients also experienced significant improvements in mean TDI total score and CAT score after switch to IND/GLY. FLAME study4 showed the 11% decrease in annual exacerbations in patients prescribed with IND/GLY compared to patients prescribed with SFC. IND/GLY patients also had a longer time to first exacerbation, compared to SFC (71 days [95% CI, 60 to 82] vs. 51 days [95% CI, 46 to 57]; hazard ratio, 0.84 [95% CI, 0.78 to 0.91]) representing a 16% lower risk (P<0.001).