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Adherence to COPD Treatment Lower With 3 Inhalers Compared With 2

Jaime Rosenberg
Patients with chronic obstructive pulmonary disease (COPD) had lower medication adherence when taking 3 inhalers compared with 2, suggesting that reducing the number of inhalers for these patients may improve adherence.
Currently, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend triple therapy for chronic obstructive pulmonary disease (COPD), which includes the combination of inhaled corticosteroids (ICS), long-acting β2-agonists (LABA), and long-acting muscarinic antagonists (LAMA) in the form of multiple inhaler triple therapy (MITT), for patients with severe symptoms who are at risk of exacerbations.

However, a new study in a real-world setting has found these patients have low adherence to and persistence with MITT, which has been shown to result in worsening of symptoms and poorer health outcomes. The researchers also found that adherence for each single inhaler was higher than adherence to MITT, suggesting that adherence could be improved by reducing the number of inhalers.

“Triple therapy has positive effects on lung function and COPD symptoms compared with dual therapy,” explained the researchers. “However, current triple therapy regimens may involve the use of multiple inhalers, which results in complex treatment regimens.”

The researchers followed 15,000 MITT users from the IQVIA Real-world Data Adjudicated Claims—USA database between January 2012 and September 2016. Patients used either 2 inhalers in the form of ICS/LABA + LAMA or LABA/LAMA + ICS or 3 different inhalers in the form of ICS + LAMA + LABA.

LAMA was most frequently used (47%) maintenance therapy, followed by ICS/LBA (43%), and ICS (8%).

Adherence to MITT was 44% at 6 months and dropped to 37% at 12 months. Meanwhile, adherence to ICS/LABA was 49% and adherence to LAMA was 54% at 12 months. Using 2 inhalers was associated with an adherence rate of 37% while using 3 inhalers was associated with an adherence rate of 32%.

Similar results were demonstrated when looking at the proportion of patients who remained adherent throughout the study period. At 6 months, 19% of patients who used 2 inhalers were adherent compared with 12% of those who used 3 inhalers, and at 12 months, 14% of patients who used 2 inhalers were adherent compared with 9% of those who used 3 inhalers.

“Although health outcomes were not recorded during this study, nonadherence has been suggested to impact the effectiveness of triple therapy and therefore improving adherence and persistence through simplification of therapy may improve health outcomes for patients with COPD,” wrote the researchers.

These results are consistent with previous systematic reviews of randomized controlled trials that have found that compared with triple therapy, treatment with LAMA monotherapy or LAMA/LABA dual therapy has resulted in decreased exacerbations and hospitalizations, as well as improved COPD-related health outcomes.


Bogart M, Stanford R, Laliberte F, Germain G, Wu J, Duh M. Medication adherence and persistence in chronic obstructive pulmonary disease patients receiving triple therapy in a USA commercially insured population [published online February 19, 2019]. Int J Chron Obstruct Pulmon Dis. doi: 10.2147/COPD.S184653.

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