Guidelines for the treatment of chronic obstructive pulmonary disease (COPD) have consistently recommended long-acting inhaled bronchodilators — either long-acting muscarinic antagonists (LAMAs) or long-acting inhaled beta-agonists (LABAs) — as initial maintenance therapy. If disease control is not achieved, as manifested by inadequate lung function and disease exacerbations, guidelines recommend their combined use.1 Although there is general agreement about the role of LAMAs and LABAs in the treatment of COPD, the role for inhaled glucocorticoids in this treatment guideline has been the object of much debate because of their modest effectiveness and concerns about safety, particularly the risk of pneumonia.2 The recent Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend that the addition of an inhaled glucocorticoid be limited to patients with severe loss of lung function and those with frequent exacerbations, termed “group D” by GOLD, despite maximized bronchodilator treatment.1 However, the evidence supporting the step-up to triple inhaled treatment (i.e., LAMA–LABA–inhaled glucocorticoid) is weak; the writers of the GOLD guideline stressed the need for research on this matter.….more