Patients With COPD on Triple vs Dual Therapy Have 7% Lower Exacerbation Risk

Triple therapy was not more effective than dual therapy in reducing exacerbation or pneumonia risks among patients with COPD who had been maintenance-naive.

Patients with chronic obstructive pulmonary disease (COPD) using triple therapy (TT; fluticasone furoate/umeclidinium/vilanterol) who are not maintenance-naïve have a 7% lower risk of exacerbations but have higher treatment costs than patients using dual therapy (tiotropium/olodaterol), according to study findings published in the Journal of Managed Care + Specialty Pharmacy.

Dual long-acting muscarinic antagonists (LAMAs)/long-acting β2-agonists (LABAs) are the preferred maintenance therapy over LAMA or LABA monotherapy for patients with chronic obstructive pulmonary disease (COPD), according to the American Thoracic Society 2020 Clinical Practice Guidelines. Patients with COPD with exercise intolerance or dyspnea may be escalated to TT (LAMA/LABA/inhaled corticosteroid [ICS]) or TT may be used as initial therapy for certain patients with high exacerbation risk.

Investigators sought to compare disease-related and all-cause health care resource utilization (HCRU) and costs, pneumonia events, and COPD exacerbations in patients with COPD initiating fixed-dose combinations of either LAMA/LABA (tiotropium/olodaterol [TIO+OLO]) or TT (fluticasone furoate/umeclidinium/vilanterol [FF+UMEC+VI]). The researchers also compared outcomes between the overall study population vs the maintenance-naïve population (ie, participants with no previous inhaled corticosteroids, LABA, or LAMA maintenance therapy in the prior 12 months).

This retrospective observational study used claims data from the Optum Research Database (including patients with commercial insurance and Medicare Advantage with Prescription Drug coverage) from June 2015 through November 2019 for patients at least 40 years of age with COPD who initiated TIO+OLO or FF+UMEC+VI. Cohorts of TIO+OLO and FF+UMEC+VI in the overall population (n=5658) and the maintenance-naïve population (n=3025) were propensity-score matched 1:1 on health care costs, health care utilization, COPD medications, comorbidities, and demographics. Clinical and economic outcomes up to 1 year in TIO+OLO vs FF+UMEC+VI post-matched cohorts were compared using multivariable regression.

A lower risk of exacerbation was observed with FF+UMEC+VI vs TIO+OLO in the overall population but not among the maintenance-naive population.

With respect to clinical outcomes in the overall study population, the investigators found no significant differences between the TIO+OLO vs FF+UMEC+VI cohorts in time to first COPD exacerbation (49.7% vs 50.8% at 1 year; P =.301) or time to first COPD severe exacerbation (18.7% vs 18.2% at 1 year; P =.459). Time to first pneumonia diagnosis was comparable across groups at 1 year, with 16.5% of patients in the dual therapy cohort vs 19.5% in the TT cohort diagnosed with pneumonia. 

In the maintenance-naïve population, investigators found there was no difference among dual and triple therapy cohorts in the adjusted risk of any exacerbation (adjusted hazard ratio [aHR], 0.99; 95% CI, 0.88-1.10). The researchers found no statistical difference for pneumonia risk between cohorts in the maintenance-naïve population (aHR, 1.13; 95% CI, 0.95-1.36) or in the overall population (aHR, 1.12; 95% CI, 0.98-1.27).

With respect to cost outcomes, investigators found that in the overall population, COPD- and/or pneumonia-related adjusted total annualized costs were significantly greater for TT ($17,633; 95% CI, 16,661-18,604) vs dual therapy ($14,558; 95% CI, 13,709-15,407; P <.001) (2020 US dollars), with patients using triple therapy paying $3075 (21.1%) more per year. Likewise, in the maintenance-naïve population, the adjusted total annualized cost of triple therapy was significantly greater than that of dual therapy (TT: $19,032; 95% CI, 17,466-20,598; vs dual therapy: $15,004; 95% CI, 13,786-16,223; P <.001; difference, $4028 [26.8%]).

Investigators noted significantly higher pharmacy costs with TT vs dual therapy, both in the overall population (TT: $6567; 95% CI, 6503-6632; vs dual therapy: $4729; 95% CI, 4676-4783; difference, $1838 [38.9%]), and in the maintenance-naïve population (TT: $6642; 95% CI, 6560-6724; vs dual therapy: $4750; 95% CI, 4676-4825; difference, $1892 [39.8%]) (all P <.001).

Notably, among the maintenance-naïve population, the FF+UMEC+VI cohort vs the TIO+OLO cohort had more annualized inpatient visits (0.5 vs 0.4; P =.029) and other medical visits (4.2 vs 3.7; P =.021).

Study limitations include selection bias and the relatively short exposure to study drugs.

“A lower risk of exacerbation was observed with FF+UMEC+VI vs TIO+OLO in the overall population but not among the maintenance-naive population,” investigators concluded. The researchers said their results indicated that real-world economic outcomes can be improved in the maintenance-naïve population with COPD by initiating dual LAMA/LABA therapy per practice guidelines.

Disclosure: This research was supported by Boehringer Ingelheim Pharmaceuticals, Inc. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Pulmonology Advisor