Introduction and current guidance

Introduction and current guidance

The NICE guideline on chronic obstructive pulmonary disease (COPD) is currently being updated (expected publication date November 2018). The current COPD guideline states that COPD is characterised by airflow obstruction that is usually progressive and not fully reversible, and is predominantly caused by smoking. COPD causes symptoms, disability and impaired quality of life, which may respond to pharmacological and other therapies that have limited or no measurable impact on the airflow obstruction. Exacerbations often occur, during which there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations.

The current NICE guideline includes the following recommendations on using inhaled therapy for managing stable COPD:

  • Short-acting bronchodilators, as necessary, should be the initial empirical treatment for the relief of breathlessness and exercise limitation.

  • In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as needed, the following should be offered as maintenance therapy:

    • if forced expired volume in 1┬ásecond (FEV1) is 50% predicted or more: either a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA)

    • if FEV1 is less than 50% predicted: either a LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or a LAMA. A LAMA should be considered in addition to a LABA if an ICS is declined or not tolerated.

  • In people with stable COPD and an FEV1 of 50% predicted or more who remain breathless or have exacerbations despite maintenance therapy with a LABA:

    • a LABA with an ICS in a combination inhaler should be considered

    • a LAMA in addition to a LABA should be considered where an ICS is declined or not tolerated.

  • In people with COPD who remain breathless or have exacerbations despite using a LABA with an ICS, a LAMA should be offered in addition to the LABA and ICS, irrespective of FEV1.

  • A LABA with an ICS in a combination inhaler should be considered in addition to a LAMA for people with stable COPD who remain breathless or have exacerbations despite maintenance therapy with the LAMA, irrespective of FEV1.

  • The choice of medication should take into account the person's symptomatic response and preference, and the medicine's potential to reduce exacerbations, its side effects and its cost.

The NICE guideline on COPD was published in 2010, which was before any of the LABA/LAMA or ICS/LABA/LAMA combination inhalers were available in the UK. Following a recent review of the evidence, the guideline is being updated (expected publication date November 2018), although triple-therapy inhalers will not be included.

This evidence summary discusses the best available evidence for the safety and efficacy of the triple combination inhaler containing beclometasone (ICS), formoterol (LABA) and glycopyrronium (LAMA; Trimbow).