The IMPACT of triple versus dual single-inhaler therapy on exacerbations of COPD

For a long time, the combination of an inhaled corticosteroid (ICS) and a long-acting β-agonist (LABA) inhaler agent was considered the mainstay of treating chronic obstructive pulmonary disease (COPD) patients with severe airflow obstruction and frequent exacerbations. More recently, the role of ICS in the treatment paradigm of patients with severe COPD and frequent exacerbations has been challenged. This is mainly driven by: 1) the growing evidence of an increased risk of pneumonia associated with ICS; 2) the introduction of combined dual long-acting bronchodilator inhalation therapy with a long-acting muscarinic antagonist (LAMA) and a LABA therapy as a plausible and likely superior treatment alternative; and 3) the recognition that probably not all COPD exacerbation phenotypes stand to equally benefit from ICS therapy, e.g. patients with high blood eosinophil counts probably stand to benefit more from ICS therapy than those with low eosinophil counts. The Informing the Pathway of COPD Treatment (IMPACT) study aimed to address the question of whether ICS in addition to dual therapy with LAMA/LABA can reduce moderate and severe acute exacerbations of COPD (AECOPD) compared with LAMA/LABA therapy alon