Context

Clinical practice guidelines (CPG) for the management of stable chronic obstructive pulmonary disease (COPD) recommend the addition of long-acting bronchodilators for patients who remain symptomatic despite use of short-acting bronchodilators.1 Whether a long-acting muscarinic antagonist (anticholinergic) bronchodilator (LAMA) such as tiotropium or a long-acting β₂-agonist bronchodilator (LABA) such as salmeterol, formoterol or indacaterol should be used as initial therapy is a matter of debate.

If symptoms persist despite the use of tiotropium, CPGs recommend adding a LABA. In practice, the LABA added usually includes inhaled corticosteroid (ICS) as a combination inhaler (LABA/ICS: salmeterol/fluticasone or formoterol/budesonide). Occasionally, a LABA/ICS is used instead of tiotropium as initial therapy, although this is not recommended by evidence-based CPGs. Finally, although commonly used for moderate-to-severe COPD, there has been little research into the effectiveness of so-called ‘triple therapy’, namely a LABA/ICS plus LAMA. This commentary examines two recent studies that have attempted to clarify these issues.