For patients with moderate to severe chronic obstructive pulmonary disease (COPD), treatment options include a long-acting beta-agonist (LABA) alone or a LABA combined with an inhaled corticosteroid (ICS). In US practice, a LABA/ICS combination is more commonly used than LABA monotherapy, but does the ICS component contribute to long-term outcomes?

Previous studies have shown that use of a LABA/ICS combination provides short-term benefits, such as symptom relief and a reduction in acute exacerbations. However, these benefits can be obtained with a LABA alone, and the incremental benefit of adding an ICS is of questionable clinical significance. We also know that use of inhaled corticosteroids has adverse effects in the long term, particularly osteoporosis and pneumonia. No single study has been able to show a mortality benefit for an ICS alone or the addition of an ICS to a LABA.

A recent study addressed the possibility that previous trials exploring the mortality question were too small to provide a definitive answer, and that combining all of the available trial results might provide a clearer answer. The study was a meta-analysis that included all prospective, double-blind, randomized trials comparing the long-term outcomes of a LABA alone vs that of a LABA-ICS combination. Read the results of this study at Medscape Today – click here

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Click here does nothing more than raised curiosity.


Try Googling Medscape


From Medscape

Meta-analysis has its shortcomings. Pooling the results of studies that are unavoidably disparate is a less-than-ideal way to derive conclusions from studies that may address important issues but are individually inconclusive. The individual trial protocols are bound to differ. However, when the question is as important as it is here -- whether there is benefit in using an ICS in every patient with COPD -- meta-analysis does have merit. A concern with this meta-analysis is that 5 of the included trials were of such short duration (2-6 months) that the possibility of detecting any effect on long-term outcomes is doubtful.

Bearing these concerns in mind, the principal outcome confirms what many of the individual studies had already indicated -- namely that the benefit of a LABA/ICS combination, in contrast to a LABA alone, is a reduction in the rate of acute exacerbations at the cost of an increased rate of pneumonia. Mortality was not altered.

The message for clinicians, therefore, is that an inhaled corticosteroid should only be included in the management of COPD if and when the patient has experienced an acute exacerbation, because that is the only benefit that the use of an ICS can definitely provide in stable COPD. Until then, an ICS should be avoided because it exposes the patient to all the risks of long-term corticosteroid use, such as a reduction in bone mineral density, cataracts, and pneumonia, without significant benefits in quality of life, lung function, or survival.


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