According to the 2024 GOLD guidelines, initial pharmacologic management of chronic obstructive pulmonary disease (COPD) is based on symptoms, exacerbation risk, and blood eosinophil count. Long-acting bronchodilators—namely, long-acting muscarinic antagonists (LAMAs) and long-acting beta 2 agonist (LABAs)—are mainstays of initial maintenance therapy. Triple therapy (LAMA, LABA, and an inhaled corticosteroid [ICS]) is recommended for high-risk patients with eosinophils of at least 300 cells/µL.

Regarding follow-up therapy, a LAMA plus a LABA should be escalated if patients experience persistent breathlessness or exacerbations on bronchodilator monotherapy. Triple therapy is recommended if there are further exacerbations on a LAMA plus a LABA. Although an ICS is appropriate in some cases, triple therapy is prevalent in COPD treatment.

A real-world study identified primary care patients newly prescribed triple therapy or a LAMA plus a LABA as initial/step-up therapy for COPD. During follow-up (≤1 year), a modest increase in all-cause mortality was observed with triple therapy versus a LAMA plus a LABA, with a higher increase among patients with no COPD exacerbations prior to initiating triple therapy. However, no increase in mortality was observed among patients with prior asthma diagnoses, 2 or more asthma exacerbations in the prior year, or moderate to severe airflow limitation.

Thus, use of triple therapy can be reassessed for many patients with COPD, as a LAMA/LABA may be sufficient before escalating to ICS.

Based on GOLD guidelines, when is it appropriate to recommend treatment for patients with COPD? How have the GOLD guidelines impacted your use of triple therapy when treating COPD?