Asthma and Emphysema: What is the Best Treatment If I Have Glaucoma??

Asthma and Emphysema: Concerns of Treatment with Glaucoma 

Dear Dr. Mahler:

What is a good medication to treat someone with ASTHMA/Centrilobular Emphysema who also has closed angle glaucoma?

Darlene from Tulsa, OK

Dear Darlene:

Both asthma and emphysema (a type of COPD) are diseases of the lung. In asthma, the primary problem is inflammation and narrowing in the breathing tubes (airways), while in emphysema the primary problem is damage/destruction of the air sacs (alveoli). In someone who had both asthma and COPD, the condition is called asthma-COPD overlap. The figure shown below illustrates the overlap between asthma and COPD (chronic bronchitis and emphysema).

Diagram shows overlap between asthma and emphysema

Diagram shows overlap between asthma and COPD (chronic bronchitis and emphysema)

It is estimated that about 25% of those with COPD have features of asthma. In general, those with both features of asthma and COPD have worse symptoms (cough and/of shortness of breath), poorer quality of life, and an increased risk of flare-ups (exacerbations) compared to those with COPD alone.

Treatment for Both Asthma and Emphysema

First, it is important that you not smoke and avoid all irritants in the air, such as dust, fumes, particles, smog, etc. Inhalers are used to treat the inflammation of asthma and bronchodilators to open the breathing tubes for both asthma and emphysema. Use of one or more inhaled medications depends to a great extent on how severe are your symptoms and whether you have had frequent flare-ups. Typically, “triple therapy” is used that includes an inhaled corticosteroid and both types of long-acting bronchodilators – beta-agonists and muscarinic antagonists.

Types of Glaucoma

You mentioned that you have “closed angle glaucoma.” As you know, glaucoma is an increase in pressure in the eye. There are two major types of glaucoma – open angle and closed or narrow angle.

In a healthy eye, excess fluid leaves the eye through the drainage angle, keeping pressure stable.

In a healthy eye, excess fluid leaves the eye through the drainage angle, keeping pressure stable.

Open angle is the most common (90%) type and typically occurs after age 50. Closed angle is usually hereditary and affects those who are far-sighted (trouble seeing near).

The prescribing information for the muscarinic antagonist bronchodilators (brand names are Atrovent, Combivent, Incruse, Seebri, Spiriva, and Turdoza) states that these medications “should be used with caution in patients with narrow angle glaucoma.” A safe approach is for you to use a combination of a beta-agonist and inhaled corticosteroid. There are different combination inhalers  (brand names are Advair, Breo, Dulera, and Symbicort) approved for treatment of asthma and/or COPD

Darlene – If these medications do not control your breathing symptoms, then you should ask your eye doctor (ophthamologist) whether a muscarinic antagonist can be tried safely.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.


Donald A. Mahler, M.D.


Triple Therapy – Trelegy Ellipta – Inhaler Approved for COPD

FDA Approves Trelegy Ellipta Dry Powder Inhaler

Background: Over the past several years, the United States Food and Drug Administration has approved numerous combination inhalers – two medications in a single inhaler for patients with COPD. These combinations include short-acting bronchodilators, four different long-acting bronchodilators, and three different long-acting bronchodilators along with an inhaled corticosteroid.

Combination inhalers are more convenient for patients than using two different inhalers. Also, there is only one co-pay with a single combination inhaler compared to two separate inhalers.

Announcement: On September 18, 2017, the FDA announced approval of a once-daily single inhaler triple therapy – three medicines in one – the brand name is Trelegy Ellipta.

FDA approves triple therapy - Trelegy Ellipta

Trelegy Ellipta dry powder inahler

This triple therapy inhaler consists of three medications that are approved in two different inhalers: 1. umeclidinium – muscarinic antagonist bronchodilator (brand name: Incruse); and 2. vilanterol (a beta2 agonist bronchodilator) combined with fluticasone furoate (an inhaled corticosteroid) (brand name: Breo).  

Indications: The press release states that the FDA approves triple therapy inhaler – Trelegy Ellipta – for the “long-term, once-daily, maintenance treatment of patients with COPD” who are: 1. already taking vilanterol and fluticasone furoate (Breo Ellipta) in whom additional bronchodilation is desired; OR 2. Those currently taking both Incruse and Breo Ellipta inhalers.

Trelegy Ellipta is not indicated for the treatment of those with asthma.

The press release also stated that the medication “will be available in the US shortly.”

European Medicines Agency (EMA): On September 15, 2017, the EMA’s Committee for Medicinal Products for Human Use issued a positive opinion recommending marketing authorization for Trelegy Ellipta – the same triple therapy inhaler approved by the FDA. 

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Tiotropium Slows Worsening (Decline in Lung Function) in Early COPD

Tiotropium Slows Worsening (Progression) in Those with Early COPD

Background: Tiotropium (brand name: Spiriva) is a once daily long-acting inhaled bronchodilator that has been approved for treatment of COPD for over 10 years. Studies show that it opens the airways to make it easier to breathe, reduces air trapped in the lungs, and improves both quality of life and ability to exercise.

Spiriva HandiHaler - tiotropium slows worsening of COPD

Spiriva HandiHaler dry powder inhaler


However, no bronchodilator has been shown to slow the expected worsening (progression) in breathing tests over time.

Study: Dr. Zhou and other investigators in China compared the changes in breathing tests of Spiriva HandiHaler and a placebo (inactive medication) over 2 years in those with “early-stage” COPD. The authors proposed that regular use of this bronchodilator would slow the expected decline in lung function as measured by expiratory volume in one second (FEV1).

FEV1 is used to grade COPD severity and assess COPD prognosis

Diagram of spirometry to diagnose COPD. FEV1 is the amount of air exhaled in one second.

Only patients with “early-stage” COPD were studied with FEV1 of 50% or higher of the predicted value. The study was conducted in 24 centers in mainland China between October 2011 and September 2015. The findings were reported in the September 7, 2017, issue of the New England Journal of Medicine, volume 377; pages 923-936.

Results: 841 patients completed the trial: 388 received tiotropium and 383 received placebo. Average age was 64 years, and 85% were men. Most patients did not complain of any shortness of breath.

The annual decline in FEV1 was significantly less in those treated with tiotropium compared with placebo when breathing tests were performed after inhaling albuterol in the pulmonary function laboratory at 2 years. The difference between treatments was 22 milliliters per year.

Conclusions: The authors concluded that tiotropium slows worsening in those with early-stage COPD as measured by post-bronchodilator FEV1.

My Comments: The current recommendations for prescribing one or two long-acting bronchodilators is to reduce symptoms and to reduce the risk of a flare-up (exacerbation) in those with COPD. However,this study challenges that approach by showing that early treatment slows progression of COPD as measured by breathing tests.

An editorial in the September 7 issue of the New England Journal of Medicine by Drs. Ko and Wong from the Chinese University of Hong Kong suggested it is likely that other long-acting bronchodilators would provide a similar benefit.

In caring for those with COPD in my practice, I have observed that many individuals have stable breathing tests when tested over several years. I believe that this stability is likely due to two factors: 1. regular use of long-acting bronchodilators; and 2. avoiding a COPD flare-up (exacerbation).

What is the Best Maintenance Bronchodilator Therapy for my COPD?

Maintenance Bronchodilator Therapy – Four Combinations Available in a Single Inhaler

Dear Dr. Mahler:

I have severe COPD and I was wondering roughly how long does it take to get on a maintenance program that works. This May will be a year and I still use my nebulizer with a duoneb every 4 hours and my emergency inhaler (Ventolin) when needed. My pulmonologist knows this. Should I see another pulmonologist??? I figure I should of been getting some relief. I have been smoke free for 3 months and will not go back to smoking again. Could you please point me in the right direction???

Jeff from Lubbock, TX

Dear Jeff:

DuoNeb is a very good short-acting combination of two different bronchodilators – albuterol and ipratropium. They work in different ways to open the breathing tubes by relaxing the muscle that wraps around the tubes. Short-acting bronchodilators last approximately 4 – 6 hours, and then the breathing tubes return to previous narrowing. Also, Ventolin is a brand name for albuterol delivered in an inhaler.

Maintenance bronchodilator therapy keep the breahting tubes open for 12 - 24 hours.

View of smooth muscle wrapping around the outside of the breathing tubes

All studies show that long-acting bronchodilators are more effective in keeping the breathing tubes open for a longer time and making it easier to breathe compared with short-acting medications. There are many choices of long-acting bronchodilators to use that are delivered in different types of inhalers.

In the past few years four different combination of long-acting bronchodilators in a single device have been approved for use in the United States by the Food and Drug Administration. I have several posts describing these medications used as maintenance bronchodilator therapy. They include in alphabetical order of brand names: Anoro Ellipta – a dry powder inhaler; Bevespi Aerosphere – a metered-dose inhaler; Stiolto Respimat – a soft mist inhaler; and Utibron Neohaler – a dry powder inhaler. Anoro and Stiolto are used once a day as their effects last for 24 hours, while Bevespi and Utibron are used twice a day because they last 12 hours.

Jeff – I suggest that you ask your pulmonologist about a trial of one of these dual long-acting bronchodilators instead of taking DuoNeb. In my practice, I give samples to be used for 2 – 4 weeks as a trial, and then schedule a follow-up appointment to assess whether the medication is helping the person “breathe easier.”

You may wish to share this post with your pulmonologist. If he or she is unwilling to try one of these long-acting combination medications, then I would consider seeing a different health care provider.

Best wishes,

Donald A. Mahler, M.D.