Are COPD patients taking triple combination inhalers being overmedicated during acute exacerbations?

Background: Triple combination inhalers containing inhaled corticosteroids (ICS), long-acting β2-adrenoceptor agonists (LABA) and long-acting muscarinic receptor antagonist (LAMA) can have beneficial effects in severe COPD not controlled on dual LABA/LAMA treatment. Their use has raised concern that patients admitted for acute COPD exacerbations may continue to receive them concurrently with nebulised short-acting muscarinic antagonist (SAMA). This has the potential to cause significant adverse effects. The extent to which this co-administration occurs in clinical practice has not been well studied to date. Methods: We assessed records of patients admitted to Oxford University Hospitals NHS in the last 6 months with primary diagnosis of acute COPD exacerbation, on a triple combination inhaler. Medication history on admission, inpatient medication chart and discharge summary were reviewed to determine treatments received and their timing. Results: 58/81(72%) were on triple combination single inhaler on admission and 23/81(28%) had one started during the admission. Co-administration of triple inhaler and SAMA was found in 40/81(49%). Triple inhaler was stopped whilst nebulised SAMA given in 24/81(30%) and 12/81(15%) had an ICS/LABA inhaler given instead. Only 6/81(8%) had the triple inhaler restarted later. Conclusion: Overmedication of LAMA and SAMA nebs at exacerbation is common. Whether SAMA is needed is unknown in patients on ICS/LABA/LAMA. Studies are needed to stop drug errors and improve outcomes.