Trimbow

  • Trimbow is a new aerosol combining an inhaled corticosteroid (beclometason) with two bronchodilators, the long-acting β2-agonist formoterol and the muscarinic receptor antagonist (parasympathicolytic) glycopyrronium.
  • Two randomised studies have compared Trimbow with a combination product containing a long-acting β2-agonist and a corticosteroid, and with a muscarinic receptor antagonist. The latter comparison is somewhat surprising as treatment in practice usually starts with a long-acting β2-agonst. If this produces insufficient relief, the guidelines recommend switching to a muscarinic receptor antagonist or adding such an agent to the treatment.
  • According to the guidelines, an inhaled corticosteroid can be considered in case of frequent exacerbations. Exacerbations are not treated with a muscarinic receptor antagonist. In light of this, it is surprising that the TRINITY study found such small differences in the average number of exacerbations per year between treatment with a muscarinic receptor antagonist and treatment with Trimbow, which contains a corticosteroid.
  • The  clinical relevance of the findings of these studies appears to be limited. The TDI scores in the TRILOGY study show that adding glycopyrronium to the therapy yields no difference in subjective symptoms of dyspnoea. The statistically significant difference in FEV1 is of secondary interest in this respect, and the average annual number of exacerbations is hardly reduced.
  • A combination product with three agents is only indicated for those patients who need this precise combination in the dosages offered. This combination product will usually not be suitable for a personalised therapy. The advantage of administering three drugs in one inhalation is that it makes it easier for the patient. On the other hand, if the patient uses an incorrect inhalation technique, this problem then automatically applies to all three drugs.
  • Trimbow is cheaper than individual inhalers (as shown in Table 3), and this could induce doctors to opt for this three-drug combination product, even though it is not recommended in the guidelines and might result in overtreatment.
  • The findings of these randomised studies show no benefit for this triple combination product. We conclude that Trimbow is a drug that offers no added value, and it is therefore rated ‘-’.

  1. Productinformatie Trimbow®. Via: www.ema.europa.eu
  2. Singh D, Papi A, Corradi M, Pavlišová I, Montagna I, Francisco C, et al. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial. Lancet 2016; 388: 963-973.
  3. Vestbo J, Papi A, Corradi M, Blazhko V, Montagna I, Francisco C, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomised controlled trial. Lancet 2017; 389: 1919–1929.
  4. Richtlijn Diagnostiek en behandeling van COPD. Utrecht: Kwaliteitsinstituut voor de Gezondheidszorg CBO, 2010.
  5. Zorgstandaard COPD. Amersfoort: Long Alliantie Nederland, 2016. Via: http://www.longalliantie.nl/zorgstandaard-copd.

Authors

  • mw drs M.A.E. Nieuwhof