Evidence‑Based Pharmacologic Management of COPD‑Asthma Overlap

Triple Therapy Benefits

Guideline Recommendations (Canadian Thoracic Society, 2023)

Additional Pharmacologic Options When Symptoms Persist

Non‑Pharmacologic and Safety Considerations

Prescribing Trelegy and Pulmicort Together

Rationale for Avoiding Concurrent Use

• The European Respiratory Society notes that pneumonia risk is higher with ICS-containing regimens (number needed to harm of 33 patients treated for one year) 3
• Adding Pulmicort to Trelegy would expose patients to two different ICS medications simultaneously, which is not supported by any guideline recommendations 4, 5, 6
• Inhaled corticosteroid therapy increases the risk of systemic adverse effects, including a 4% increased risk of pneumonia compared to non-ICS regimens 4, 6

Appropriate Use of Trelegy

• The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends triple therapy for patients in categories C and D with severe airflow obstruction (FEV₁ <50% predicted) and frequent exacerbations 5, 7
• Triple therapy like Trelegy is recommended for patients with persistent moderate to severe dyspnea despite dual therapy, and for patients at high risk of COPD exacerbations (≥2 exacerbations per year or ≥1 hospitalization) 3, 8, 9

Common Clinical Pitfalls

• Avoid adding Pulmicort to Trelegy in an attempt to "boost" ICS therapy for patients with persistent symptoms, as this represents irrational polypharmacy 4, 5
• When transitioning patients from dual ICS/LABA therapy (like Pulmicort/formoterol) to Trelegy, discontinue the previous ICS-containing regimen rather than continuing both 3, 7

Alternative Approaches if Trelegy is Insufficient

• For patients with chronic bronchitis phenotype and FEV₁ <50% predicted still experiencing exacerbations on Trelegy, add roflumilast rather than additional ICS 3
• Evaluate for pulmonary rehabilitation, oxygen therapy, or treatment of comorbidities rather than medication duplication 4, 5