Asthma and COPD in general practice: Trelegy, triple therapy, and why not everyone starts on ICS

Dr Jonathan Banks

Respiratory and sleep physician, Gold Coast. About six years locally; Coastal Respiratory and Sleep. Consults John Flynn, Pindara and Pimpama Health Precincts. He declared an honorarium for this evening’s presentation.

Room and host

Industry-hosted GP education. The host (Otter Speaker 1) framed Trelegy Ellipta and Arexvy, then handed over. Dr Kotha is audible in the questions (Otter heard “Dr Kathari”). Otter split the room into Speaker 1–13; Speaker 3 is Dr Banks.

Burden, and why Ventolin-only is not a plan

The host opened on a number Dr Banks later underlined: in 2023, 480 people in Australia died of asthma. Preventable, with the therapies we already have — including biologics. COPD remains a leading cause of hospitalisation and death.

Picture struggling to shower, climb stairs, or walk with family. Patients normalise that. They over-use Ventolin, adapt, and live smaller. The ask to the room: which of your asthma and COPD patients would benefit from a review, and who is lining up for the next flare?

Dr Banks: respiratory and sleep physician, Gold Coast about six years, public then private. He started Coastal Respiratory and Sleep because the corridor from south Brisbane to the Northern Rivers is, in his view, under-serviced. The plan is multidisciplinary — nurse practitioners, pathways — not another solo rooms model. Lung cancer has been a recent teaching interest; tonight the brief was Trelegy Ellipta, “one of the easiest and most user-friendly devices.”

Kate: dual therapy asthma that is still not controlled

Kate is in her forties. Asthma for about twenty years. Nocturnal symptoms a few times a month — he called that a red flag. Symptoms on moderate exercise. One course of prednisolone a year. Already on dual therapy: inhaled corticosteroid plus LABA, plus as-required salbutamol. FEV1 about 68%.

Real-world point he wanted on the table: of people with asthma on ICS/LABA dual therapy, more than half still have symptoms. Adherence is the obvious reason. We should not have people dying of asthma in Australia.

Control, as he uses it: history first. Asthma Control Test, or ACQ-5. How often, how dyspnoeic, how much reliever, school or work missed, and how they rate it themselves.

Options on the slide for Kate: increase the ICS dose; add a LAMA as a second inhaler; switch to a single-inhaler triple; or refer. National Asthma Council: consider adding a LAMA when they are already on medium or high-dose ICS.

He talks biologics early with new asthma patients, not because everyone needs one tomorrow, but because prednisolone is a dangerous drug. It works. Patients like it. Doctors like the quick win. Cumulative exposure starts to matter around 500 mg, and the slide also showed about 1000 mg — osteoporosis, pneumonia, cardiovascular and metabolic disease, mood. Every extra course is a reason to ask what you missed first.

CAPTAIN, ETHER, and Trelegy 200 in asthma

CAPTAIN compared triple Trelegy with dual ICS/LABA (he described switching from a Seretide-equivalent onto the Ellipta, including Trelegy 200). Even in a short washout of a few weeks, FEV1 lifted, then kept lifting.

Both Trelegy 100 and 200: adding the LAMA improved FEV1 versus dual therapy. There was a signal toward fewer exacerbations that was not statistically significant in the way he described it — he still flagged exacerbations as mortality and morbidity, not a soft outcome. ACQ-7 symptoms improved versus Breo (same ICS/LABA backbone, no LAMA). Safety of stepping dual to triple: he said the extra agent did not light up a significant harm signal in that data.

Then ETHER — physiology, not a mega-trial. Xenon as an MRI tracer. Uneven ventilation in obstructive disease: the lung is many units, not one balloon. After about six weeks of Trelegy 200 in more symptomatic patients, ventilation looked more homogeneous. Small airways opening. Mucus plugging down. Forced oscillation technique (FOT) — airway resistance without a spirometry blow, more used in paediatrics — also improved small-airway resistance on Trelegy 200. Safety: no signal he called out.

A GP asked if particle size matters for small airways. One company promotes in-silico particle stories. He tends to ignore that. Does size matter? Probably. You are treating small airways that have muscle, not alveoli. It does not have to be nanoparticle.

Robert: COPD, missed evening doses, two exacerbations

Sixty-six. Ex-smoker. Grandchildren are the point of the week, and the lungs are getting in the way. Dual ICS/LABA plus salbutamol. Until twelve months ago, puffers only. Twice-daily dosing — forgetting evenings. Two respiratory tract infections in a year needing prednisolone and antibiotics.

Many COPD patients are still symptomatic on dual therapy. He hopes GPs are not reaching for ICS as the first COPD puffer. Exacerbations matter for long-term lung function, quality of life, and death. After a viral illness, coronary events cluster — he had a human metapneumovirus patient at John Flynn who came back with a sizeable NSTEMI. Once COPD exacerbations start, that is a mortality marker.

Evidence he walked for switching to Trelegy 100 versus a moderate-dose ICS/LABA (Symbicort in his wording): better lung function, better St George’s respiratory questionnaire, fewer exacerbations. “For me personally, I think that’s the big key.” Same device, adding LAMA beyond dual: benefit. ICS on top helps exacerbation risk — one reason to add ICS in frequent exacerbators. Eosinophils: another reason he steps COPD patients toward ICS. Biologics targeting that eosinophilic pathway are coming for COPD in Australia. He expects an avalanche of “there’s a new injection” referrals. Optimise the inhaler first.

No company wants a true head-to-head. So registry data. US Medicare: Trelegy versus Breztri — fewer exacerbations on Trelegy, statistically clearer in the moderate group than the hospitalised severe group. UK registry versus Trimbow (Trelegy not listed there, Trimbow not in the US): lower moderate-to-severe exacerbations on Trelegy; pneumonia signal similar. Limitations: not randomised, not the highest rung of evidence. His counter: trials are carefully selected people you do not see on a Tuesday. Large real-world numbers still teach. Anecdotally, he has seen a lot of positive responses versus the local competitor.

Why not triple for everyone — GOLD A, B, E as he taught it

Dr Kotha asked the obvious clinic question: guidelines start SAMA/SABA, then LAMA/LABA — why not put everyone on triple and prevent the first lost FEV1? Because once they exacerbate, function does not come all the way back.

Dr Banks: ICS in COPD has a pneumonia signal. And resource. Triple inhalers are expensive — the room landed on about $104 a month. He has been watching families leave private cover and private schools. He still wants GPs to follow the stepwise chart. Lung Foundation Australia is the website he pointed people at.

Later, GOLD as he recalled it: groups A, B, E, updated regularly, based on exacerbations and symptom score.

• Asymptomatic, no exacerbations: you do not really have to start anything.
• Mild symptoms: a single agent (LAMA or LABA in his wording).
• Truly exacerbating: two moderate exacerbations, or any hospitalisation — a role for inhaled corticosteroid.

LAMA versus LABA head-to-heads: older data, roughly similar, small differences in large groups. He does not pay those trials much attention. Carefully selected patients.

Pharmacotherapy last: smoking, Arexvy, rehab, reflux

Most of what he does in clinic is not the inhaler. The inhaler is the last thought.

• Smoking cessation — easy to skip when the clock is running.
• Avoid cruises — Dr Kotha’s line; Banks laughed and remembered ICU at Royal Brisbane: you could tell when a ship docked by the 70-year-olds who arrived horribly unwell.
• Vaccines — Arexvy, now generally available over 75, which the host had already plugged for RSV in hyperinflated asthma and COPD lungs.
• Pulmonary rehabilitation — hard for him to refer (no Smart Refer); some private options; he is trying to get more mid-Gold Coast capacity. Nutrition, exercise, chest clearance.
• Comorbidity — if a COPD patient has none, something is wrong. Cardiovascular disease. Metabolic disease.
• Reflux — he used to be a sceptic. Keeps coming back to it.

Then, and only then, optimise the drug.

Once a day, slow breath, hold five to ten seconds

Both Trelegy strengths are once daily. Devices were on the table. He used to be sceptical that very severe COPD could manage a dry powder. They can. He historically favoured MDI plus spacer; he is less worried now, because people come back taking it.

Script he teaches: nice, big, slow, deep breath. Hold five to ten seconds. Visualise the particles going down. Then you are done. Rescue MDIs look simple and are often terrible in the room — sprayed at the ceiling, chewed. RespiClick-type devices: great delivery, hard to use. The inhaler-therapy chart keeps growing. Easier device, more chance the prescription actually happens.

Real-world adherence: once daily beats twice daily, which is not a surprise. Forget the morning dose? Take it later. His first question at review is not “are you short of breath?” — it is have you had an exacerbation, have you been on antibiotics, since last time?

MART, FeNO, azithromycin, spirometry, prednisolone

MART in asthma, not as a COPD habit

MART (maintenance and reliever; SMART when it was Symbicort) is, for him, the right asthma approach. Anti-inflammatory reliever for an inflammatory small-airway disease — we spent decades handing out salbutamol and calling it treatment. If they already like a device, he may add Symbicort (or equivalent MART) on top of regular therapy rather than force one inhaler for everything. In hospital he will use ICS-containing dual therapy frequently — he mentioned three puffs four times a day as an inpatient pattern to get on top of inflammation; not six times a day.

MART in COPD? He has not seen the data and does not do it routinely. If airways disease is exacerbating and eosinophils are up, targeting that with ICS-containing therapy is reasonable. “Pure COPD” is less common than the room thinks; the other direction is more true. Long-term untreated asthmatic inflammation — 70s and 80s, type 2 diabetes, obesity, sleep apnoea, years of prednisolone — ends as fixed airflow obstruction: fibrosis, remodelling, muscle hypertrophy. Even on biologics, keep some ICS. You can drop the dose. Do not leave airway inflammation unchecked for twenty or thirty years.

FeNO

FeNO tracks airway inflammation, mainly IL-4 and IL-13, and whether ICS is actually landing. It does not diagnose asthma — supportive only. Public labs (in his telling) often keep people on therapy for testing; some private labs ask them to stop 24–48 hours. His analogy: you would not stop the antihypertensive the day before clinic BP. For a first diagnosis, off-therapy FeNO and a challenge test can help. High FeNO plus eosinophils: you can push specific pathways. No T2 profile: harder. That is a patient he might use azithromycin on.

Azithromycin and bronchiectasis

Immunomodulatory more than antibiotic. Dose he quoted: 250 mg, half a tablet, three times a week. Not willy-nilly. Resistance (strep) and C. difficile risk exist and are small at that dose in his experience. Most asthma patients he can get to a biologic via eosinophils or another inflammatory profile. In bronchiectasis the infection burden is already high; resistance worry is more Pseudomonas. First-line there is not another steroid puffer — it is chest clearance: AirPhysio / Aerobika, nebulised saline, percussion. Oscillating PEP is “so, so good.” ICS in labelled-as-asthma-or-COPD bronchiectasis is often a mislabel, and extra steroid in a dirty airway is more of a problem.

Theophylline, lung volume reduction, the chest x-ray that is not COPD

Theophylline: rarely in the last couple of years. Narrow window, cardiac and neurologic toxicity, interactions. We have better options.

Hyperinflated COPD: think lung-volume-reduction type options in selected people. He prefers one interventional path over another — Otter garbled the device names (heard as “OKID” versus “the optimum”), so those labels are not invented here.

COPD is a spirometry diagnosis, not an x-ray of hyperinflated lungs. About one patient a fortnight arrives labelled COPD from radiology, no risk factors, and a list of mimics that share the same symptoms. If you are about to prescribe small-airway therapy, confirm small-airway obstruction.

Take-home messages for clinic

1. 480 asthma deaths in Australia in 2023 is too many. Patients shrink their lives around Ventolin. Review who is actually controlled.
2. More than half of dual-therapy asthmatics still have symptoms. Confirm the diagnosis, confirm they take it, then treatable traits, then step up. Medium/high-dose ICS is when NAC considers a LAMA.
3. Prednisolone is not a harmless rescue. Cumulative harm from around 500–1000 mg. His bar for “too many courses” is one. Talk biologics early so you are not farming steroids.
4. CAPTAIN: Trelegy triple vs dual ICS/LABA — FEV1 up, symptoms up, LAMA is doing real work. Exacerbation signal, not a slam-dunk p-value as he told it. ETHER: six weeks of Trelegy 200, xenon MRI more even, less mucus, better small-airway resistance on FOT.
5. COPD exacerbations are a mortality marker (and a coronary-risk marker after viruses). Dual ICS/LABA plus missed evening doses plus two steroid/antibiotic hits is the classic step-up-to-triple patient — Trelegy 100 in the sponsor wrap.
6. Not everyone starts on triple. ICS pneumonia risk, ~$104/month, follow the stepwise chart. GOLD A/B/E as he said it: nothing if asymptomatic; single bronchodilator if mildly symptomatic; ICS if two moderate exacerbations or a hospitalisation.
7. Eosinophils help him add ICS in COPD. Biologics for that pathway are coming; optimise inhaled therapy first.
8. Inhaler last. Smoking, Arexvy over 75, pulmonary rehab, chest clearance, heart and metabolic disease, reflux. Then the puffer.
9. Watch the device. Once daily, slow deep breath, hold 5–10 seconds. Ellipta is easy enough that even severe COPD often manages DPI. MART for asthma; not his COPD routine.
10. Diagnose COPD on spirometry. FeNO supports inflammation, it does not diagnose asthma. Azithromycin 250 mg three times a week is a specialist-style immunomodulatory option for non-T2 airways, not a default GP script. Bronchiectasis: clearance before another ICS.

Dr Kotha · Gold Coast · copd.drkotha.com