The role of triple therapy in the management of COPD.

It is still unclear whether and when addition of an ICS to the LAMA/LABA combination provides real additional clinical value, regardless of a preventive effect on exacerbations. There are many doubts about the value of the blood eosinophil count as a valid biomarker to predict AECOPD risk and the clinical response to ICS, also because no association was found in observational studies. In any case, before starting a therapy involving ICS, the risk factors for the development of pneumonia must always be evaluated. Adding a LAMA to an ICS/LABA combination seems to be less problematic. However, each LABA/LAMA combination has a specific efficacy/safety profile that needs to be considered for personalized therapy in COPD even in the context of triple therapy.