Don’t Combine These COPD Medicines

Most people with chronic obstructive pulmonary disease (COPD) use an inhaler every day to control shortness of breath and other symptoms of this progressive lung disease.

There are many different kinds of inhalers. Some are used once or twice a day to manage COPD and prevent acute exacerbations (attacks). Others are used as needed when an exacerbation occurs. As a result, most people with COPD use several different inhalers as part of the treatment plan.

Classes of COPD Inhaler Medications

There are different classes of inhaled medications used in the treatment of COPD.

Among them are:

• Antimuscarinic drugs: These reverse airway narrowing by acting on a nerve transmitter called acetylcholine.
• Long-acting beta-agonists (LABAs):These relax the airways by working on receptors in the lungs known as beta-2 adrenergic receptors.
• Short-acting beta-agonists (SABAs): These work like LABAs but are used as rescue inhalers rather than for daily use.
• Inhaled steroids: These improve breathing by reducing inflammation.
• Combination phosphodiesterase (PDE) 3 and 4 inhibitors:These relax airway muscles and lessen inflammation by targeting PDE3 and PDE4 receptors in the lungs

Possible Concerns

While multiple inhalers may be prescribed for COPD, not all can be used together safely. Combining certain inhalers can lead to health risks.

Possible concerns include:

• Overdosing: Some inhalers contain one drug, while others have two or three. This raises the risk of an overdose if the same drug is present in different inhalers.
• Increased side effects: Inhalers from the same drug class can cause similar symptoms. Using two inhalers from the same class can heighten the risk or severity of side effects.
• Interactions: Certain inhaler drugs can interact with others, potentially leading to severe low blood potassium (hypokalemia) and heart rhythm problems (cardiac arrhythmia).

Combinations That Are Safe or Unsafe

Some inhalers can be used together safely, while others cannot. It’s important to be aware of these combinations if you or a loved one is undergoing treatment for COPD.

Antimuscarinic Inhalers

Controller medications are those used to control symptoms of COPD and prevent exacerbations. Antimuscarinic drugs are controller medications used once or twice daily.

Drug	Class	Consideration	Reason	​
Atrovent HFA (ipratropium)	Antimuscarinic	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Incruse Ellipta (umeclidinium)	Antimuscarinic	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Spiriva (tiotropium)	Antimuscarinic	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Tudorza (aclidinium)	Antimuscarinic	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Anoro Ellipta (umeclidinium/vilanterol)	Antimuscarinic, LABA	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Bevespi Aerosphere (glycopyrrolate/formoterol)	Antimuscarinic, LABA	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Stiolto Respimat (tiotropium/olodaterol)	Antimuscarinic, LABA	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Trelegy Ellipta (fluticasone/umeclidinium/vilanterol)	Antimuscarinic, LABA, inhaled steroid	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​
Combivent Respimat (ipratropium/albuterol)	Antimuscarinic, SABA	Should not be used with other medications containing antimuscarinic drugs	Increased risk of side effects	​

Beta-Agonists

Beta-2 adrenergic agonists (also known as beta-agonists) are a mainstay treatment for COPD. There are short-acting versions used as rescue inhalers and long-acting versions that are used to control COPD.

​	Class	Consideration	Reason
Albuterol (generic)	SABA	OK to take with LABAs	N/A
Brovana (arformoterol)	LABA	OK to take with SABAs	N/A
Foradil (formoterol)	LABA	OK to take with SABAs	N/A
Perforomist (formoterol)	LABA	OK to take with SABAs	N/A
Serevent (salmeterol)	LABA	OK to take with SABAs	N/A
Striverdi Respimat (olodaterol)	LABA	OK to take with SABAs	N/A

Inhaled Steroids

Inhaled glucocorticoids (also known as inhaled steroids) are commonly used in combination with other inhaled drugs to control COPD. They are mainly used in people with a history of exacerbations.

​	Class	Consideration	Reason
Advair (fluticasone/ salmeterol)	Inhaled steroid and LABA	OK to take with SABAs	N/A
Symbicort (budesonide/formoterol)	Inhaled steroid and LABA	OK to take with SABAs	N/A
Fluticasone (generic)	Inhaled steroid	Do not use with Advair or Symbicort as they contain similar steroids	Increased risk of hypokalemia and heart rhythm problems
QVAR (beclomethasone)	Inhaled steroid	Do not use with Advair or Symbicort as they contain similar steroids	Increased risk of hypokalemia and heart rhythm problems
Breo Ellipta (fluticasone/vilanterol)	Inhaled steroid and LABA	OK to take with SABAs	N/A

By Lauren Van Scoy, MD

Lauren Van Scoy, MD, is a board-certified physician in internal medicine, pulmonary medicine, and critical care.

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