Tribrez(5.5 mcg+10.4 mcg+182 mcg)

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is an FDA-approved, guideline-supported triple fixed-dose combination inhaler indicated for the long-term, twice-daily maintenance treatment of two chronic obstructive airway diseases. It is not a rescue inhaler and must not be used to relieve sudden breathing problems.

Established/Approved Indications

• Maintenance treatment of chronic obstructive pulmonary disease (COPD) in adults, including chronic bronchitis and/or emphysema, to reduce exacerbations and improve lung function and symptoms.
• Maintenance treatment of asthma in adults and pediatric patients 12 years of age and older whose disease is not adequately controlled on an inhaled corticosteroid and a long-acting bronchodilator, or whose disease severity warrants initiation of triple therapy.

Not Indicated For

• Relief of acute bronchospasm or acute exacerbations (it is not a rescue/reliever medicine; a separate short-acting bronchodilator must be available for acute symptoms).
• Primary treatment of status asthmaticus or other acute episodes requiring intensive measures.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is always used as maintenance/controller therapy and is prescribed by a physician after assessment of disease severity.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is supplied as a pressurized metered-dose inhaler (pMDI) delivering a fixed combination of three active ingredients per actuation:

• Formoterol fumarate (dihydrate) – a long-acting beta2-adrenergic agonist (LABA)
• Glycopyrrolate – a long-acting muscarinic antagonist (LAMA)
• Budesonide – an inhaled corticosteroid (ICS)

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is available in more than one approved strength; the specific strength dispensed depends on whether it is prescribed for COPD or for asthma, as directed by the prescriber. It also contains pharmaceutically inert propellants and excipients required for aerosol delivery.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is a triple-therapy inhaled medicine that combines a long-acting bronchodilator of the beta-agonist class, a long-acting bronchodilator of the anticholinergic (antimuscarinic) class, and an anti-inflammatory corticosteroid in a single pressurized inhaler. Combining all three mechanisms in one device is intended to provide bronchodilation from two complementary pathways together with control of airway inflammation, for patients whose COPD or asthma is not adequately controlled with dual therapy alone.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is administered by oral inhalation twice daily and is intended for regular, ongoing maintenance use rather than as-needed symptom relief.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) belongs to the therapeutic class of triple fixed-dose combination inhalers for obstructive airway disease, combining:

• Long-Acting Beta2-Agonist (LABA)
• Long-Acting Muscarinic Antagonist (LAMA)
• Inhaled Corticosteroid (ICS)

It is used within the pulmonology/respiratory medicine therapeutic category for chronic maintenance management of COPD and asthma.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) works through the complementary actions of its three components:

• Formoterol fumarate stimulates beta2-adrenergic receptors on airway smooth muscle, activating adenylyl cyclase and increasing intracellular cyclic AMP, which relaxes bronchial smooth muscle and produces bronchodilation with a rapid onset and duration of action of approximately 12 hours.
• Glycopyrrolate antagonizes acetylcholine at M3 muscarinic receptors on airway smooth muscle, blocking vagally-mediated bronchoconstriction and reducing mucus gland secretion, providing a second, complementary long-acting bronchodilator effect.
• Budesonide binds to intracellular glucocorticoid receptors, suppressing multiple inflammatory cell types (eosinophils, mast cells, lymphocytes) and inflammatory mediators, reducing airway inflammation, mucosal edema, and hyperresponsiveness.

Together, the pharmacology of Tribrez (5.5 mcg+10.4 mcg+182 mcg) provides dual-pathway bronchodilation plus anti-inflammatory control in a single device, improving lung function and reducing the frequency of exacerbations compared with individual or dual-component therapy in clinical trials.

Proper inhaler technique is essential for Tribrez (5.5 mcg+10.4 mcg+182 mcg) to work effectively:

• Shake the inhaler well before each use.
• Prime the inhaler before first use and if it has not been used for a prolonged period, per the instructions in the patient leaflet.
• Breathe out fully, place the mouthpiece between the lips, and inhale slowly and deeply while pressing down on the canister; hold the breath for about 10 seconds before exhaling.
• Wait about 1 minute between the two inhalations of a dose.
• Rinse the mouth with water and spit it out after each dose to reduce the risk of oral thrush (candidiasis) and hoarseness.
• Do not use Tribrez (5.5 mcg+10.4 mcg+182 mcg) more often or at higher doses than prescribed.
• Keep a separate short-acting rescue inhaler on hand at all times for sudden symptoms, since Tribrez (5.5 mcg+10.4 mcg+182 mcg) is not for acute relief.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) has the following clinically significant drug interactions:

• Beta-blockers (including cardioselective agents and ophthalmic preparations): may antagonize the bronchodilator effect of the formoterol component of Tribrez (5.5 mcg+10.4 mcg+182 mcg) and can produce severe bronchospasm; concomitant use should generally be avoided in patients with obstructive airway disease.
• Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants: may potentiate the cardiovascular effects (e.g., QT prolongation, tachycardia) of the formoterol component; use Tribrez (5.5 mcg+10.4 mcg+182 mcg) with caution, and avoid within 2 weeks of stopping an MAOI.
• Non-potassium-sparing diuretics (e.g., loop or thiazide diuretics): ECG changes and/or hypokalemia associated with the formoterol component may be worsened by concomitant non-potassium-sparing diuretics; use with caution and monitor potassium.
• Other adrenergic drugs (sympathomimetics): concomitant use may potentiate cardiovascular adverse effects of the formoterol component.
• Other anticholinergic/antimuscarinic medicines: concomitant use with the glycopyrrolate component of Tribrez (5.5 mcg+10.4 mcg+182 mcg) may increase antimuscarinic adverse effects (e.g., dry mouth, urinary retention, constipation) and should generally be avoided.
• Strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir, itraconazole): may significantly increase systemic exposure to the budesonide component of Tribrez (5.5 mcg+10.4 mcg+182 mcg), raising the risk of corticosteroid-related adverse effects, including adrenal suppression; concomitant use should be avoided when possible.

Most people tolerate Tribrez (5.5 mcg+10.4 mcg+182 mcg) well, but side effects can occur.

Common Side Effects

• Oral candidiasis (thrush), throat irritation, hoarseness/dysphonia
• Nasopharyngitis and upper respiratory tract infections
• Headache
• Cough
• Back pain
• Urinary tract infection
• Nausea
• Tremor and palpitations (from the bronchodilator components)

Serious but Less Common Side Effects

Serious risks such as paradoxical bronchospasm, cardiovascular effects, pneumonia (in COPD patients), hypersensitivity reactions, and effects on the adrenal glands and bone density are discussed in detail under Precautions and Warnings.

Patients should contact their physician promptly if side effects are severe, persistent, or concerning.

Pregnancy: There are limited human data on the use of Tribrez (5.5 mcg+10.4 mcg+182 mcg) in pregnant women. Tribrez (5.5 mcg+10.4 mcg+182 mcg) should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus, and only under a physician's guidance. Poorly controlled asthma or COPD during pregnancy itself carries risks to mother and baby, so treatment should not be stopped without medical advice.

Lactation: It is not known whether the components of Tribrez (5.5 mcg+10.4 mcg+182 mcg) pass into human breast milk in clinically significant amounts. Because many drugs are excreted in breast milk, caution should be exercised, and Tribrez (5.5 mcg+10.4 mcg+182 mcg) should be used during breastfeeding only if clearly needed, with the infant monitored for any adverse effects; a physician should be consulted before use.

Boxed Warning: LABA Class Effect

Medicines containing a long-acting beta2-agonist (LABA), such as the formoterol component of Tribrez (5.5 mcg+10.4 mcg+182 mcg), increase the risk of asthma-related death when the LABA is used as monotherapy (without an inhaled corticosteroid) for asthma. This risk is mitigated when a LABA is combined with an inhaled corticosteroid, as in Tribrez (5.5 mcg+10.4 mcg+182 mcg); nonetheless, this class warning is disclosed for Tribrez (5.5 mcg+10.4 mcg+182 mcg) as a matter of safety labeling.

Other Precautions

• Not for acute symptoms: Tribrez (5.5 mcg+10.4 mcg+182 mcg) is not a rescue medicine and should never be used to treat acute bronchospasm.
• Local corticosteroid effects: Oral candidiasis is common; rinse the mouth after each dose. Localized infections of the mouth and throat may occur.
• Immunosuppression: As with other corticosteroid-containing medicines, Tribrez (5.5 mcg+10.4 mcg+182 mcg) should be used with caution in patients with active or quiescent tuberculosis, untreated systemic fungal, bacterial, or viral infections, or ocular herpes simplex, because inhaled corticosteroids can mask or worsen infection.
• Pneumonia: An increased incidence of pneumonia has been observed in COPD patients using ICS-containing medicines; monitor for signs of pneumonia.
• Cardiovascular effects: The formoterol component can produce clinically significant cardiovascular effects (tachycardia, arrhythmias, and rarely QT prolongation); use Tribrez (5.5 mcg+10.4 mcg+182 mcg) with caution in patients with cardiovascular disease, arrhythmias, or hypertension.
• Anticholinergic effects: The glycopyrrolate component has antimuscarinic activity; use Tribrez (5.5 mcg+10.4 mcg+182 mcg) with caution in patients with narrow-angle glaucoma or urinary retention/bladder outlet obstruction (e.g., prostatic hyperplasia), as it may worsen these conditions.
• Hypokalemia and hyperglycemia: Beta-agonists can produce transient hypokalemia and hyperglycemia; monitor as clinically indicated, particularly at higher doses.
• Adrenal insufficiency: Patients transferring from chronic systemic corticosteroid therapy to Tribrez (5.5 mcg+10.4 mcg+182 mcg) require gradual, physician-supervised tapering; hypothalamic-pituitary-adrenal (HPA) axis suppression can occur with long-term use.
• Bone density: Long-term use of inhaled corticosteroids, including the budesonide component of Tribrez (5.5 mcg+10.4 mcg+182 mcg), may be associated with decreased bone mineral density.
• Growth effects: ICS-containing medicines may cause a reduction in growth velocity in pediatric patients; growth should be monitored.
• Paradoxical bronchospasm: Tribrez (5.5 mcg+10.4 mcg+182 mcg) can, uncommonly, produce paradoxical bronchospasm; discontinue immediately if this occurs and treat with an alternative bronchodilator.

Overdose of Tribrez (5.5 mcg+10.4 mcg+182 mcg) may produce exaggerated effects of its individual components: excessive beta-agonist effects (tachycardia, tremor, headache, hypokalemia, hyperglycemia, arrhythmias, seizures), anticholinergic toxicity from the glycopyrrolate component (dry mouth, blurred vision, urinary retention, constipation, tachycardia), and, with prolonged excessive use, corticosteroid-related effects (hypothalamic-pituitary-adrenal axis suppression) from the budesonide component.

There is no specific antidote for Tribrez (5.5 mcg+10.4 mcg+182 mcg) overdose. If overdose is suspected, seek immediate medical attention or contact emergency services/a poison control center. Treatment is supportive, with cardiac and electrolyte monitoring as directed by a physician; a cardioselective beta-blocker may be considered by a physician only with extreme caution due to the risk of bronchospasm.

Store the inhaler between 20°C and 25°C (68°F to 77°F); brief excursions to 15°C-30°C are permitted during travel. Store with the mouthpiece down. Do not puncture, break, or burn the canister, even when it appears empty, and avoid exposure to direct sunlight, extreme heat, or freezing temperatures, as the canister may burst. Keep out of the reach and sight of children.

• Renal impairment: No formal dose adjustment of Tribrez (5.5 mcg+10.4 mcg+182 mcg) has been established; use with caution as systemic exposure to the components has not been extensively studied in severe renal impairment.
• Hepatic impairment: Because budesonide is metabolized by the liver, patients with hepatic impairment may have higher systemic corticosteroid exposure from Tribrez (5.5 mcg+10.4 mcg+182 mcg); use with caution and monitor for corticosteroid-related adverse effects, especially in severe hepatic impairment.
• Elderly patients: No overall differences in safety or effectiveness have been established relative to younger adults, but elderly patients may be more sensitive to cardiovascular and anticholinergic effects; use with appropriate monitoring.
• Pediatric patients: See Pediatric Uses.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is intended for long-term, continuous maintenance treatment of COPD or asthma and should be used every day, twice daily, for as long as prescribed by the physician, even when symptoms are well controlled. It is not intended for short-term or intermittent use. Any decision to step down or stop Tribrez (5.5 mcg+10.4 mcg+182 mcg), particularly the corticosteroid component after prolonged use, should be made gradually and only under medical supervision, as abrupt discontinuation can worsen disease control or precipitate adrenal insufficiency symptoms.

Triple fixed-dose combination bronchodilator/anti-inflammatory: Long-Acting Beta2-Adrenergic Agonist (LABA) + Long-Acting Muscarinic Antagonist / Anticholinergic (LAMA) + Inhaled Corticosteroid (ICS).

Tribrez (5.5 mcg+10.4 mcg+182 mcg) acts through three distinct, complementary mechanisms delivered together:

• Formoterol fumarate (LABA): selectively stimulates beta2-adrenergic receptors in airway smooth muscle, activating adenylyl cyclase, raising intracellular cyclic AMP, and causing smooth muscle relaxation and bronchodilation lasting approximately 12 hours.
• Glycopyrrolate (LAMA): competitively blocks acetylcholine at M3 muscarinic receptors on airway smooth muscle, inhibiting vagally-mediated bronchoconstriction and reducing mucus secretion, producing sustained bronchodilation independent of the beta-agonist pathway.
• Budesonide (ICS): diffuses into airway cells and binds glucocorticoid receptors, which translocate to the nucleus and modulate gene transcription, suppressing the production of inflammatory cytokines and reducing the recruitment and activation of eosinophils, mast cells, and lymphocytes, thereby reducing airway inflammation and hyperresponsiveness.

The combined mode of action of Tribrez (5.5 mcg+10.4 mcg+182 mcg) addresses both the bronchoconstriction and the underlying airway inflammation that drive COPD and asthma symptoms.

Tribrez (5.5 mcg+10.4 mcg+182 mcg) is approved for maintenance treatment of asthma in adolescents 12 years of age and older, at the strength indicated for asthma, when their disease is not adequately controlled on dual controller therapy. Safety and effectiveness of Tribrez (5.5 mcg+10.4 mcg+182 mcg) for asthma in children younger than 12 years have not been established, and Tribrez (5.5 mcg+10.4 mcg+182 mcg) should not be used in this age group. Tribrez (5.5 mcg+10.4 mcg+182 mcg) is not approved for the treatment of COPD in any pediatric population, as COPD does not typically occur in children. As with other inhaled corticosteroid-containing medicines, Tribrez (5.5 mcg+10.4 mcg+182 mcg) may cause a reduction in growth velocity in pediatric patients, and growth should be monitored periodically by the treating physician during long-term use.