Review: long-acting beta2-agonists and inhaled corticosteroids reduce exacerbations in chronic obstructive pulmonary disease.

and commentary also appear in ACP Journal Club and EvidenceBased Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For correspondence: Dr D D Sin, James Hogg iCAPTURE Center for Pulmonary and Cardiovascular Research, Vancouver, British Columbia, Canada. [email protected] Sources of funding: Canadian Institutes of Health Research and Alberta Heritage Foundation for Medical Research. Summary of efficacy data for interventions for chronic obstructive pulmonary disease* Comparisons RRR/RRI (95% CI) Exacerbation Mortality LAb2A v placebo RRR 21% (10 to 31) RRR 24% (248 to 61) Tiotropium v placebo RRR 26% (11 to 38) NA Tiotropium v LAb2A RRR 7% (28 to 20) NA Tiotropium v ipratropium RRR 22% (5 to 37) NA SAb2A + anticholinergic v SAb2A RRR 32% (9 to 49) RRI 18% (266 to 308) SAb2A + anticholinergic v ipratropium RRI 4% (235 to 68) RRI 256% (241 to 2053) Inhaled corticosteroids v placebo RRR 24% 20 to 28) RRR 22% (25 to 42) Inhaled corticosteroids + LAb2A v placebo RRR 30% (22 to 38) RRR 48% (234 to 80) Inhaled corticosteroids + LAb2A v LAb2A RRR 20% (10 to 29) NA Inhaled corticosteroids + LAb2A v inhaled corticosteroids RRR 10% (22 to 20) NA Pulmonary rehabilitation v usual care, placebo, or education NA RRR 10% (224 to 35) Supplemental O2 v usual care (patients with resting PaO2 , 60 mm Hg sea level) NA RRR 39% (18 to 54) Supplemental O2 v usual care (patients with resting PaO2 > 60 mm Hg sea level) NA RRI 16% (215 to 58) Disease management v usual care NA RRR 37% (24 to 62) *LAb2A = long acting b2 agonist; SAb2A = short acting b2 agonist; NA = not assessed. Other abbreviations defined in glossary; RRR, RRI, and CI calculated from data in article. Not significant. Commentary T he review by Sin et al covers a wide range of treatments for COPD. Breadth is achieved at the expense of detail, but the authors provide a useful overview. A major criticism of respiratory medicine has been the absence of large, long term studies. In the controversial area of inhaled corticosteroid therapy for COPD, an attempt was made to rectify this paucity with several reasonably large studies that lasted >3 years. These studies provided some important answers, but still left unanswered questions. 2 meta-analyses 2 published in 2003 found a slower decline in FEV1 with inhaled corticosteroids compared with placebo, but the difference was ,10 ml/y, and the authors came to opposite conclusions on the importance of the finding. These meta-analyses included more studies than the review by Sin et al, but the lack of available details makes comparisons difficult. Recent studies of COPD have concentrated on clinically relevant outcomes, such as exacerbations, quality of life, and admissions, although definitions of exacerbations vary. LAb2As, tiotropium, and inhaled corticosteroids all reduce exacerbations by 20–30% relative to placebo. The added benefits of combination therapies on various endpoints are difficult to extricate and need further study. Corticosteroids seem to add to the effect of LAb2As. The results provide a good case for LAb2As or tiotropium in patients with more than mild COPD and inhaled corticosteroids in patients with more severe disease. Good evidence exists on the benefits of rehabilitation in the short to medium term, although there is uncertainty on how to maintain the initial benefit, and many countries have difficulty providing adequate respiratory rehabilitation programs. Smoking cessation and long term oxygen therapy are the only treatments that significantly improve the natural history and life expectancy of patients with COPD. New treatments may offer further benefits in COPD; this review provides a basis for optimal use of current treatments. P John Rees, MD Guy’s, King’s and St Thomas’ School of Medicine, London, UK 1 Highland KB, Strange C, Heffner JE. Ann Intern Med 2003;138:969–73. 2 Sutherland ER, Allmers H, Ayas NT, et al. Thorax 2003;58:937–41. THERAPEUTICS 79 www.evidence-basedmedicine.com group.bmj.com on August 14, 2017 Published by http://ebm.bmj.com/ Downloaded from