LAUSR

The combination of 2 long-acting bronchodilators, a 2-agonist (LABA), and an antimuscarinic agent (LAMA) in a single inhalation device, known as double bronchodilation,1 has changed therapeutic strategies in chronic obstructive pulmonary disease (COPD). Studies evaluating the safety and efficacy of this modality have placed it at the forefront of current COPD treatment recommendations, while inhaled corticosteroids (ICS) are reserved as an alternative combined with double bronchodilation as a second treatment step in group C exacerbators or the more severe group D patients.2 In this context, the new GOLD 2017 strategy recommends the use of ICS in patients receiving double bronchodilation who continue presenting exacerbations. Consequently, there is a need to combine various drugs and inhalation devices to combine a LABA, a LAMA and an ICS to construct the so-called triple therapy using two inhalation devices. Before the introduction of double bronchodilation, only 2 methods of administering this triple combination of drugs was available: either 3 drugs had to be administered via 3 different devices, or else a fixed ICS/LABA combination had to be used with a LAMA in another inhaler. The introduction of double bronchodilation now allows another alternative: a fixed LABA/LAMA combination together with an ICS in another inhaler, raising questions as to which strategy is the most appropriate. On one hand, according to the current GOLD 2017 treatment algorithm, patients who are candidates for triple therapy have already been receiving double bronchodilation. So, while the GOLD 2017 document does not specify how this triple therapy should be administered, it seems logical to assume that, according to the GOLD 2017 recommendations, double bronchodilation in 1 device could be continued while adding an ICS in a separate device. However, on the other hand,3 suggesting that the triple therapy combination should be approached by adding the LAMA to the fixed ICS/LABA combination. Moreover, the real situation is more complex and real-world prescriptions do not always strictly follow recommendations,4 complicating the issue even further.