NICE and new inhalers for COPD

The 2010 NICE guidelines on COPD are currently under review as these were published before any LABA/LAMA or ICS/LABA/LAMA combination inhalers were available.

One of the NICE evidence summaries to have been developed this year discusses the safety and efficacy of Trelegy, the triple combination inhaler containing fluticasone furoate (ICS), umeclidinium (LAMA) and vilanterol (LABA). Trelegy is licensed for the maintenance treatment of adults with moderate-to-severe COPD who are not adequately treated by an ICS/LABA combination.

Trelegy has been shown to reduce the annual rate of moderate or severe exacerbations by 15 per cent compared with fluticasone furoate/vilanterol, but NICE considers 20 per cent to be the minimum clinically important difference. It may be suitable for some people with moderate-to-severe COPD who have found triple therapy beneficial using more than one inhaler, who have difficulty using multiple inhalers and can use a dry powder inhaler.

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

Trimbow may be suitable for some people with moderate-to-severe COPD who have found triple therapy beneficial using more than one inhaler and can use a pressurised metered dose inhaler (with or without a spacer), but find it difficult to use several inhalers. NICE advises clinicians to take safety, efficacy, cost and patient factors into account when considering prescribing Trimbow.

Risks with using inhalers

The MHRA has received reports of patients who have inhaled objects into the back of the throat while using pressurised metered dose inhalers (pMDI) resulting in coughing and, in some cases, airway obstruction when objects were aspirated. Patients should be reminded, when removing the mouthpiece cover before use, to check the inside for any loose debris and to shake the inhaler to remove any loose objects. If damage has occurred the cover should be replaced.

A safety issue has also occurred with Braltus (tiotropium), with the MHRA reporting a risk of inhalation of the capsule when patients place it in the mouthpiece of the inhaler rather than in the chamber. Patients need to be educated on the correct use, ensuring they store the capsules safely and always check the mouthpiece is clear before inhaling.