MIMS summary of NICE COPD guidance updated

Prescribers can now consult the quick-reference MIMS summary of NICE COPD guidance for the latest advice on the use of inhaled triple therapy.

NICE makes separate recommendations on triple therapy for people taking LABA + ICS and those taking LAMA + LABA.

The MIMS summary of NICE COPD guidance includes the latest recommendations on the use of inhaled triple therapy for stable COPD and on the duration of systemic corticosteroids for managing exacerbations.

Switching from LABA + ICS

For people with COPD who are taking a long-acting β agonist and an inhaled corticosteroid (LABA + ICS), NICE recommends offering triple therapy with LAMA + LABA + ICS if: 

  • their day-to-day symptoms continue to adversely impact their quality of life, or
  • they have a severe exacerbation (requiring hospitalisation), or
  • they have 2 moderate exacerbations within a year.

In these patients, the evidence showed that switching to LAMA + LABA + ICS reduced the rate of severe exacerbations, improved FEV1, and did not increase the risk of pneumonia or other serious adverse events.

Switching from LABA + LAMA

For people who are taking a long-acting anticholinergic (muscarinic antagonist) and a LABA (LAMA + LABA), NICE concluded that swtiching to triple therapy reduces the rate of serious exacerbations and provides some quality of life improvement. However, these improvements were smaller than those seen in people switching from LABA + ICS to triple therapy. In addition, people who switched from LAMA + LABA to triple therapy were more likely to get pneumonia.

The committee therefore recommended that triple therapy with LAMA + LABA + ICS be considered in patients taking LAMA + LABA if:

  • they have a severe exacerbation (requiring hospitalisation) or
  • they have 2 moderate exacerbations within a year.

NICE also says a 3-month trial of triple therapy can be considered for patients taking LAMA + LABA whose day-to-day symptoms adversely impact their quality of life. If symptoms have not improved after 3 months, triple therapy should be stopped and switched back to LAMA + LABA.

The 3-month trial is recommended to help identify people with less severe symptoms who will benefit from triple therapy, while ensuring that people who do not benefit can easily switch back to LAMA + LABA. At the end of the trial, prescribers should explicitly ask patients whether taking the drug improved their COPD symptoms.

Before starting triple therapy in any patient, prescribers should ensure that:

  • the person's non-pharmacological COPD management is optimised and they have used or been offered treatment for tobacco dependence if they smoke
  • acute episodes of worsening symptoms are caused by COPD exacerbations and not by another physical or mental health condition
  • the person's day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition. 

There are currently two triple combination inhalers for prescribers to choose from: Trelegy Ellipta (fluticasone/vilanterol/umeclidinium) and Trimbow (beclometasone/formoterol/glycopyrronium).

Shorter corticosteroid course

Guidance on the use of systemic corticosteroids for managing exacerbations has also been updated. If breathlessness increases sufficiently to interfere with daily activities, NICE now recommends offering prednisolone 30mg daily for a shorter course of 5 days rather than the previously advised 7−14 days. 

Treatment is recommended for 5 days because the evidence showed no benefit from taking corticosteroids for more than 7 days and shorter courses of 5 days are routinely used in clinical practice already.

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