Improved COPD outcomes with combined long-acting beta-agonist and inhaled steroid therapy

1. Compared to the use of long-acting β-agonists (LABAs) alone, combination therapy with LABAs and inhaled steroids resulted in a slightly lower risk of death or hospitalization among chronic obstructive pulmonary disease (COPD) patients.

2. COPD patients with concurrent asthma and those not taking long-acting anticholinergics had a significantly lower risk of death or hospitalization when treated with combination therapy compared to LABAs alone.

Evidence Rating Level: 2 (Good)           

Study Rundown: The management of COPD is primarily achieved through medical therapy. LABAs (long-acting βagonists) and inhaled corticosteroids are some of the mainstays of treatment, promoting bronchodilation and decreasing airway inflammation, respectively. However the most efficacious therapeutic regimen – the administration of LABAs alone or the administration of LABAs in combination with inhaled corticosteroids – remains unclear. While previous studies demonstrated an association between combination therapy and a decreased number of COPD exacerbations, these studies failed to include older patients and patients with comorbidities, thereby limiting the generalizability of their results.

This study examined the composite outcome of mortality and COPD hospitalizations in COPD patients taking LABA-corticosteroid combination therapy versus LABAs alone. Importantly, older patients with comorbidities were included in the study population. There was a moderate but statistically significant lower risk of death or COPD hospitalizations in patients using combination therapy compared to patients using LABAs alone. Subgroup analyses revealed a lower risk in individuals with concurrent asthma and in those who were not taking long-acting anti-cholinergics, another class of medications utilized in COPD treatment.

This study is limited by factors inherent to its observational cohort design, particularly unmeasured confounding factors, and inaccuracies in classification related to its reliance on medical record review for the diagnosis of COPD. Nevertheless, this study corroborates prior findings supporting the use of combination therapy for COPD and further extends these findings to include older patients with comorbidities as well.

Click to read the study, published today in JAMA

Click to read the accompanying editorial, published today in JAMA

Relevant Reading: Combined corticosteroid and long-acting beta-agonist in one inhaler versus long-acting beta-agonists for chronic obstructive pulmonary disease

In-Depth [cohort study]: This study was a longitudinal cohort study that included patients, age 66 years and older, with physician-diagnosed COPD evident on chart review. Patients that were new users of LABAs (n=3160, after matching) or LABA-corticosteroid combination therapy (n=8712, after matching) between 2003 and 2011 were included. New users of combination LABA-corticosteroid had a slightly lower risk of the composite outcome compared to new uses of LABAs alone (HR, 0.92; 95%CI, 0.88-0.96). This lower risk was also observed in stratified groups: patients with a diagnosis of asthma (HR, 0.84; 95%CI, 0.77-0.91) and those not taking long-acting anti-cholinergic medications (HR, 0.79; 95% CI, 0.73-0.86).

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