COPD Controller Combo May Lower Death Risk

Treating chronic pulmonary obstructive disease with both inhaled corticosteroids and long-acting bronchodilators remains controversial, but new evidence suggests that this controller combination could reduce mortality risk.

Treating chronic pulmonary obstructive disease (COPD) with both inhaled corticosteroids and long-acting bronchodilators remains controversial, but new evidence suggests that this controller combination could reduce mortality risk.

COPD treatment has improved in the last 20 years. Currently, most guidelines recommend chronic therapy with long-acting bronchodilators—products that include long-acting beta2-agonists (LABAs)—or tiotropium for moderate-to-severe COPD.

A common clinical approach to selecting a product is this: the clinician prescribes tiotropium for an appropriate trial followed by a LABA (or vice versa), and then the COPD patient chooses the treatment that he or she prefers.

There is still some debate over which treatment approach is better: long-acting bronchodilators alone or a combination treatment that adds inhaled corticosteroids to the equation.

Some studies indicate that inhaled corticosteroids do not modify COPD's course and often introduce risk for adverse effects such as oropharyngeal candidiasis and hoarseness.

One unresolved issue has been inhaled corticosteroids’ potential effect on mortality.

Regardless, clinicians often prescribe (and guidelines recommend) inhaled corticosteroids for patients who experience repeated COPD exacerbations.

A new study that appears in the Journal of Chronic Obstructive Pulmonary Disease analyzed whether adding inhaled corticosteroids to long-acting bronchodilator therapy reduces mortality, and it did provide evidence that this addition may prevent deaths.

The researchers identified a cohort of 18,615 adult patients discharged from a hospital with a COPD diagnosis between 2006 and 2009.

Participants included patients defined as new long-acting bronchodilator users or those also on inhaled corticosteroids who were classified as “LB alone” or “LB+ICS” initiators.

The researchers recorded occurrence of out-of-hospital exacerbations in the 6 months preceding follow-up to identify patients with potential greater susceptibility to exacerbation.

Among the participants, 12,207 initiated “LB+ICS” therapy, and 6408 used “LB alone.”

In the monotherapy arm of the study, 143 patients (2.23%) died. In the combination arm, 110 patients (0.9%) died, and the mortality reduction was more pronounced in those who experienced frequent COPD exacerbations.

When analyzing patients with recent out-of-hospital exacerbations, the benefit of the combination therapy was pronounced.