The combination of a long-acting β22-agonist (LABA) and an inhaled corticosteroid (ICS) may be the best choice for some patients with chronic obstructive pulmonary disease (COPD) who need more than short-acting bronchodilators, suggest the results of a Cochrane Collaboration network meta-analysis.
“Quality of life and lung function were improved most on combination inhalers (LABA and ICS) and least on ICS alone at 6 and at 12 months”, report Kayleigh Kew (St George’s, University of London, UK) and colleagues.
“Our findings are in keeping with current NICE [National Institute for Health and Care Excellence] guidelines”, they write in Cochrane Database Systematic Reviews, noting that treatment usually starts with a single, short-acting bronchodilator and progresses to the use of additional short- or long-acting inhalers as required.
They highlight that the aim of treatment is to relieve symptoms, improve exercise tolerance and quality of life, as well as to slow the decline in, if not improve, lung function. Preventing and treating exacerbations is also important.
“[I]t is important to understand the merits of these treatments relative to each other, and whether a particular class of inhaled therapies is more beneficial than the others”, Kew and team state.
A total of 71 randomised controlled trials of at least 6 months duration were identified as of September 2013, involving 73,062 patients with COPD treated with LABA, long-acting muscarinic antagonists (LAMA), ICS, LABA/ICS or placebo.
As expected, there was a preponderance of male participants, most of whom were in their mid 60s and had substantial smoking histories of 40 or more pack years. Baseline lung function, measured as the forced expiratory volume in 1 second (FEV1) predicted normal as being between 40% and 50%.
The mean improvement in quality of life, measured using the St George’s Respiratory Questionnaire (SGRQ) total score, was highest for the LABA/ICS combination, with a difference over placebo of 3.89 units at 6 months and 3.60 units at 12 months. Corresponding mean differences in SGRQ total score for LAMA, LABA and ICS at 6 months were 2.63 units, 2.29 units and 2.00 units, respectively.
The mean improvement in FEV1 with the LABA/ICS combination over that of placebo was 133.3 mL at 6 months and 100.0 mL at 12 months. Corresponding values at 6 months for LAMA, LABA and ICS were 103.5 mL, 99.4 mL and 65.4 mL, respectively.
“Class differences between LABA, LAMA and ICS were less prominent at 12 months”, say the researchers. This applied to both quality of life and lung function measures.
Kew et al caution, however, that this analysis only looked at efficacy and therefore emphasise that “the additional expense of combination inhalers and any potential for increased adverse events (which has been established by other reviews) require consideration.”
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