Do we need three players in COPD treatment?

daily, SFC 50/250 μg twice daily, or Tio 18 μg once daily plus SFC 50/250 μg twice daily. Pulmonary function, CT, and assessment of health-related quality of life were carried out at screening and at the end of treatment. The right upper lobe apical segmental bronchus (RB1) was chosen for the analysis. The luminal area (Ai), total area of the airway (Ao), wall area (WA = Ao – Ai), percentage wall area (WA% = WA/Ao × 100), and absolute wall thickness were automatically computed. The addition of Tio to SFC significantly increased the Ai and decreased the airway wall thickness. Furthermore, FEV 1 significantly increased in the Tio-plus-SFC group compared with the other groups and this effect was correlated with the changes in Ai and WA. Anatomical and functional changes were associated with greater improvements in SGRQ subscores of symptoms and activity in the Tioplus-SFC group compared with the Tio, SM, and SFC groups. To our knowledge, this is the first study relating triple therapy with the combination of two bronchodilators and an ICS to CT scan measures of airways wall structural changes. Despite the limited number of patients studied, the authors were careful in controlling for confounders; measurements were standardized for body surface area, and lung volume and total airway dimensions were assessed and were not modified by treatment. Therefore, the changes were due to a redistribution of Ai and WA. Chronic obstructive pulmonary disease (COPD) is a common respiratory disease that represents the third leading cause of death and disease burden worldwide. By definition, it is treatable, but the effectiveness of the current treatment is unsatisfactory since it results in little changes in the natural history of the disease [1] . Drugs for stable COPD reduce the symptoms, frequency, and severity of exacerbations and improve the quality of life and exercise tolerance, but none of them consistently attenuate the progressive decline in FEV 1 . The positive effects on FEV 1 decline obtained with an inhaled corticosteroid/ long-acting β 2 -agonist (ICS/LABA) combination or tiotropium (Tio) have been demonstrated only in post hoc analysis or subanalysis of the TORCH and UPLIFT studies [2, 3] . Furthermore, few data have been reported on the ability of the current drugs to modify biomarkers of remodeling in COPD patients [4, 5] . Triple combination therapy with anticholinergics, ICS, and LABA improved pulmonary function and symptoms in COPD patients [6] , but the mechanism behind the increased efficacy has not been studied. In the current issue of Respiration, Hoshino and Ohtawa [7] report the effects of Tio plus salmeterol and fluticasone propionate (SFC) on airway dimensions as assessed by chest tomography (CT) scan in COPD patients. A total of 60 COPD patients were treated for 16 weeks with Tio 18 μg once daily, salmeterol (SM) 50 μg twice Published online: August 28, 2013