Combination therapy for COPD associated with better outcomes

A combination of a long-acting beta-agonist (LABA) and inhaled corticosteroid (ICS) therapy was associated with a lower risk of death or hospitalization among older adults with chronic obstructive pulmonary disease (COPD), particularly those with asthma, compared with LABAs alone, a study found.

The study included data from 8,712 new users of LABA-ICS combination therapy and 3,160 new users of LABAs alone who were followed for a median of 2.7 years and 2.5 years, respectively, from 2003 to 2011 in Ontario. Results appeared in the Sept. 17 Journal of the American Medical Association.

The primary outcome, a composite of death and COPD hospitalization, was observed among 2,129 new users of LABAs alone. There were 1,179 deaths (37.3%) and 950 COPD hospitalizations (30.1%) in those patients. In the LABA-ICS group, the primary outcome occurred among 5,594 people, with 3,174 deaths (36.4%) and 2,420 COPD hospitalizations (27.8%). This worked out to a modest but significant reduction in risk of the composite outcome in the combination group at 5 years (−3.7%; 95% CI, −5.7% to −1.7%; hazard ratio [HR], 0.92; 95% CI, 0.88 to 0.96). Similarly lower risks were also observed for mortality and COPD hospitalizations analyzed separately.

In subgroup analysis, there was a statistically significant reduction in risk of death or hospitalization on LABA-ICS treatment among those with asthma (HR, 0.84; 95% CI, 0.77 to 0.91), those not receiving long-acting anticholinergics (HR, 0.79; 95% CI, 0.73 to 0.86), and those who had not previously received spirometry (HR, 0.87; 95% CI, 0.81 to 0.93). Three-way interaction among treatment, long-acting anticholinergics use, and asthma was not significant (P=0.31). But patients who did not have asthma and were not receiving long-acting anticholinergics had a significantly lower risk of death or hospitalization on LABA-ICS treatment (HR, 0.83; 95% CI, 0.75 to 0.92).

“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,” the authors wrote. The results provide guidance in optimal treatment for COPD patients both with and without asthma, they concluded.

An editorial noted that the most noteworthy feature of the study was 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,” the editorial stated.