September 24, 2014
COPD Patients With Asthma Especially Benefit From Combination Therapy

Toronto, Canada—Two therapies are better than one for older adults with chronic obstructive pulmonary disease (COPD), especially if they also have asthma.

A new study published recently in the Journal of the American Medical Association finds that initiating long-acting beta-agonists (LABAs) and inhaled corticosteroids (ICS) together, compared with just newly prescribed LABAs alone, was associated with a lower risk of death or COPD hospitalization.

With COPD the third leading cause of death worldwide, a team led by researchers at the Sunnybrook Health Sciences Centre and Institute for Clinical Evaluative Sciences in Toronto examined the outcomes of LABA-ICS combination therapy compared with LABAs alone in older COPD patients with other illnesses, including asthma.

The study, which included data from 2003 to 2011 on patients 66 years or older in Ontario who had been diagnosed with COPD, focused on 8,712 new users of LABA-inhaled corticosteroid combination therapy and 3,160 new users of LABAs alone. The two groups were followed up for a median of 2.7 years and 2.5 years, respectively.

During the study period, 37.3% of 2,129 new users of LABAs alone died and another 30% were hospitalized with COPD. Of the 5,594 new users of LABAs and ICSs combined, however, 36.4% died and 27.8% were hospitalized. The difference in composite outcomes at 5 years was 3.7%.

“New use of LABAs and inhaled corticosteroids was associated with a modestly reduced risk of death or COPD hospitalization compared with new use of LABAs alone,” the authors note.

In COPD patients with a co-diagnosis of asthma, however, the difference in composite outcomes at 5 years was 6.5%. For patients who were not receiving inhaled long-acting anticholinergic medication, the difference grew to 8.4%.

“Our finding of an association between LABAs and ICSs and outcomes helps clarify the management of patients with COPD and asthma, as many studies of COPD medications have excluded people with asthma and vice versa,” write the authors, who call for randomized clinical trials to confirm their findings. “In addition, practice guidelines for COPD recommend that LABAs be considered first-line treatment while asthma guidelines warn against use of LABAs without ICSs. Our findings also offer insight into the optimal treatment of COPD patients without asthma—those who would not be considered especially corticosteroid responsive.”

Peter M. A. Calverley, M.B.Ch.B., DSc, of the University of Liverpool, England, adds in an accompanying editorial, “Perhaps the most noteworthy feature of the new data reported … is the difference in the characteristics of the patients who use these treatments from those in whom therapy was validated in randomized clinical trials (RCTs). The outcomes of treatment in these 'real-world' patients were somewhat better than might have been expected from RCTs, but the patients were also much more diverse and often sicker.”

Calverley suggests that the study “shows that findings from appropriately conducted database analyses complement data from RCTs and should be considered when determining treatment algorithms.”

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