An increasing array of inhaled medicines is now available on the PBS for treating and managing airways disease, for both asthma and chronic obstructive pulmonary disease (COPD), often with different proprietary devices for delivery. Indeed each of the last four issues of RADAR has contained reviews on one or another of these medicines.

In this issue, along with a new combination product for asthma, we review two more inhaled medicines for COPD now listed on the PBS — umeclidinium (Incruse Ellipta) a long-acting anticholinergic, and a new combination product (Ultibro Breezhaler) delivering a fixed-dose combination (FDC) of indacaterol, a long-acting beta-2 receptor agonist, with glycopyrronium, a long-acting anticholinergic.

Rapid change in options for treating and managing COPD, including increasing availability of FDC products, and the bewildering list of brand names for active ingredients and their corresponding proprietary devices, has potential to create confusion. To help prescribers keep pace with these changes, in this issue we provide a summary of current PBS-listed single-agent and FDC products for use in COPD (see In Brief article Pharmacological therapies for COPD in Australia).

Regardless of the choice of COPD medicine, there are several important key messages to keep in mind when considering these products:

  • follow a stepwise approach: start with a short-acting reliever — a short-acting beta-2 agonist (SABA) or short-acting anticholinergic/muscarinic antagonist (SAMA) — as needed for symptom relief, before adding maintenance therapy with one or more long-acting bronchodilators
  • add an inhaled corticosteroid to a long-acting bronchodilator for patients who remain symptomatic
  • certain medicines need to be discontinued before others are started — check guidelines for recommendations about combination therapy
  • inhaler technique is crucial for achieving optimal benefit — assess at every visit and especially before considering any step-up in treatment.

Whenever considering an FDC product remember that the benefits of patient convenience and reduced cost may be offset by the reduced options for dose titration and the increased difficulty in attributing side effects if they occur. And, to avoid doubling up, always advise patients to return the medicines that they are replacing to a pharmacy for disposal.

For more advice on prescribing FDCs visit the NPS MedicineWise website topic on combination medicines.

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