Triple therapy for symptomatic patients with COPD

Combination therapy is almost the standard for treating chronic diseases, including chronic obstructive pulmonary disease (COPD). Until 2016, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendation for highly symptomatic COPD patients at risk of exacerbations or severe airflow limitation (GOLD D) was treatment with either long-acting muscarinic antagonists (LAMA) or long-acting β2-agonists (LABA) in combination with inhaled glucocorticosteroids (ICS), both with strong evidence. Triple therapy with LAMA/LABA/ICS was also recommended, but with panel consensus judgment, that is, based upon expert opinion only. To our knowledge, no properly powered and sufficiently long randomised clinical trial has ever shown that triple therapy is superior to LAMA, LABA/LAMA, or LABA/ ICS in reducing exacerbations as the primary outcome. However, one short study assessing lung function showed a significant reduction in exacerbations by triple therapy compared with LABA/ICS at 3 months.