Environmentally friendly inhaler regimens for COPD

Triple therapy of an inhaled corticosteroid, long acting β₂-agonist (LABA), and long acting muscarinic antagonist (LAMA) is more effective in reducing the annual rate of exacerbations compared with LABA-LAMA or LABA-inhaled corticosteroid in patients with chronic obstructive pulmonary disease (COPD), a history of exacerbations, and high symptom burden in pivotal randomised trials.1234 However, this treatment combination is associated with a 1.52-fold to 1.96-fold increased incidence of pneumonia.34 Triple therapies are available with different LABA, LAMA, and inhaled corticosteroid drugs, and in different inhaler devices such as dry powder inhalers and propellant-containing metered dose inhalers. Given interclass differences in pharmacological and physiochemical properties of LABAs, LAMAs, and inhaled corticosteroids,56 different triple therapy combinations may lead to varying clinical outcomes. The release of hydrofluoroalkanes from metered dose inhalers has been linked to green gas emissions; replacing metered dose inhalers with dry powder inhalers has been advocated to reduce the carbon footprint of health care.7 However, head-to-head comparisons of LABA-LAMA-inhaled corticosteroid triple therapy combinations and metered dose inhaler versus dry powder inhaler in people with COPD remain limited.

In a linked study (doi:10.1136/bmj-2024-080409), Feldman and colleagues assessed comparative effectiveness and safety of a single metered dose inhaler budesonide-glycopyrrolate-formoterol …