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The American Journal of Managed Care April 2019
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Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms
Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
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Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms

Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
Changing patients from an inhaled corticosteroid (ICS)/long-acting β agonist (LABA) inhaler and long-acting muscarinic agonist (LAMA) inhaler to a LAMA/LABA inhaler and a separate ICS inhaler did not appear to affect patient-reported chronic obstructive pulmonary disease (COPD) symptom scores.
Changing patients who require triple therapy to a regimen containing a LAMA/LABA inhaler and an ICS inhaler would show drug cost savings to the patient, as well as the healthcare system. Using our insurer’s formulary as an example, a Medicare patient would pay 2 co-pays of $45 each for an ICS/LABA inhaler and a LAMA inhaler. If changed to a LAMA/LABA inhaler and an ICS inhaler, the patient would pay a $45 co-pay and a $15 co-pay, respectively. Medicare patients would take longer to meet the threshold for the coverage gap and would have lower monthly costs during that time because ICS inhalers have a lower average wholesale price.13 The LAMA/LABA inhaler and ICS inhaler combination would also simplify future step-down to dual therapy with a LAMA/LABA inhaler in patients whose COPD remains well controlled and no longer requires triple therapy.

In our patient population, 77% in the quality improvement project and 79% in the research group had Medicare plans through the insurer. According to cost data provided by the insurer, Medicare patients saved $30 per month out of pocket and $115 in total drug costs. Commercially insured patients would also have received cost savings in the form of reduced monthly co-payments. Based on the 19 patients who changed regimen and using a cost difference between regimens of $115 per month, the insurer would save $26,220 annually. Extrapolating these savings to the other 99 potential patients from the original population would yield an additional $136,620 in savings for the insurer annually. This highlights the importance of finding less expensive regimens while maintaining adequate efficacy, as seen in our study population.


A small sample size limited this study. Common barriers were that patients refused the recommended change (n = 27), the physicians denied the change (n = 7), or the patients changed the regimen by stopping one inhaler or returning to their previous regimen (n = 7). Reasons for returning to the previous regimen were not recorded but could have been due to unfamiliarity with a newly prescribed device or worsening symptoms. The sample mostly accounts for Medicare patients living in the northeastern United States, which may limit the widespread applicability.

COPD exacerbations have been shown to be more frequent during winter months.14 As the quality improvement project took place over a period of time between fall 2016 and spring 2017, seasonality may have affected patients’ symptom scores.

Patient-reported symptom scores are a subjective measure. Although the CAT is a validated test, there may be variability in the perceived severity of symptoms among patients. The same person made all the calls to patients, which eliminated interrater variability. Additionally, patients were asked to think about symptoms over a 2-week period, which may have led to recall bias. We attempted to avoid interpatient variability by evaluating the mean difference in CAT scores instead of individual scores.

Lastly, this project focused on COPD symptoms and treatment assessed with scripted phone calls. Adherence was not a major focus of the quality improvement project, so nonvalidated methods were used. We could not assess the accuracy of each patient’s inhalation technique, although patients were asked if they had issues with their devices. We did not include questions about events or interventions related to comorbid conditions. Data from patients with exacerbations were excluded from analysis because we attempted to assess stable patients. Three patients had acute respiratory issues during the review period. The hospital notes and costs associated with these exacerbations were unavailable for review. Although drug costs were decreased, as noted previously, the total cost of COPD care may have been negatively affected without our knowledge.


This study did not show any significant change in COPD symptoms when inhalers were changed to a less expensive combination in a small sample of patients. Given the limitations noted, this would need to be confirmed with randomized controlled studies with a greater focus on total cost of care.


Dr Ladziak is now employed with University of Arizona College of Pharmacy, Phoenix, Arizona, and Banner University Medical Center Phoenix Family Medicine Clinic, Phoenix, Arizona.

The authors thank Troy Hoelzl, PharmD candidate, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, for his work with patient outreach and data collection.

Author Affiliations: University at Buffalo School of Pharmacy and Pharmaceutical Sciences (NL, NPA), Buffalo, NY; Buffalo Medical Group, PC, Pharmacy Department (NL, NPA), Buffalo, NY.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (NL, NPA); acquisition of data (NL, NPA); analysis and interpretation of data (NL, NPA); drafting of the manuscript (NL, NPA); critical revision of the manuscript for important intellectual content (NL, NPA); and statistical analysis (NL, NPA).

Address Correspondence to: Nick Ladziak, PharmD, University of Arizona College of Pharmacy, 650 E Van Buren St, Office 3373, Phoenix, AZ 85004. Email:

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