The analysis done in the SPRUCE (SPiRiva Usual CarE) trial suggests that a benefit may be gained by adding tiotropium to combined inhaled corticosteroid and long-acting beta-adrenergic receptor agonist therapy in patients with COPD. However, evidence will need to be provided by the Canadian Optimal Therapy of COPD Trial, which was designed to evaluate this drug combination, before definite conclusions can be drawn about the potential benefit of triple therapy in this population. It will be important to see the impact that this treatment regimen has on clinically meaningful outcomes, such as the frequency of exacerbations and the number of hospital visits, and to see if these correlate with changes in spirometric measures.