Combination therapy of inhaled steroids and long-acting beta-agonists versus inhaled steroids alone

Nannini LJ, Cates CJ, Lasserson TJ, Poole P

Published Online:

January 20, 2010

Combinations of two classes of medication (long-acting beta-agonists and inhaled corticosteroids) in one inhaler have been developed to treat people with COPD as it may make it easier to take the medication . Two brands of combined inhaler exist currently: budesonide/formoterol (BDF - 'Symbicort'), and fluticasone/salmeterol (FPS - 'Advair' or 'Seretide'). The results of the studies showed that BDF and FPS were effective and reduced the frequency of flare ups compared with inhaled corticosteroid alone. The studies showed that on average there was a relative reduction of 9% in the mean rates of exacerbations. The impact of this difference on individuals will vary depending on how frequently they experience exacerbations. Quality of life and lung function showed improvements with combination treatment compared with steroids. Future research should assess the benefits and harms of BDF since the majority of evidence to date has been drawn from FPS studies.

Abstract (click to read)

Background:

Long-acting beta-agonists and inhaled corticosteroids have both been recommended in guidelines for the treatment of chronic obstructive pulmonary disease. Their co-administration in a combined inhaler is intended to facilitate adherence to medication regimens, and to improve efficacy. Two preparations are currently available, fluticasone/salmeterol (FPS) and budesonide/formoterol (BDF).

Objectives:

To assess the efficacy of combined inhaled corticosteroid and long-acting beta-agonist preparations, compared to inhaled corticosteroids, in the treatment of adults with chronic obstructive pulmonary disease.

Search strategy:

We searched the Cochrane Airways Group Specialised Register of trials. The date of the most recent search is April 2007.

Selection criteria:

Studies were included if they were randomised and double-blind. Studies compared combined inhaled corticosteroids and long-acting beta-agonist preparations with the inhaled corticosteroid component.

Data collection and analysis:

Two reviewers independently assessed trial quality and extracted data. The primary outcome were exacerbations, mortality and pneumonia. Health-related quality of life (measured by validated scales), lung function and side-effects were secondary outcomes. Dichotomous data were analysed as fixed effect odds ratios or rate ratios with 95% confidence intervals, and continuous data as mean differences and 95% confidence intervals.

Main results:

Seven studies of good methodological quality met the inclusion criteria randomising 5708 participants with predominantly poorly reversible, severe COPD. Exacerbation rates were significantly reduced with combination therapies (Rate ratio 0.91; 95% confidence interval 0.85 to 0.97, P = 0.0008). Data from two FPS studies indicated that exacerbations requiring oral steroids were reduced with combination therapy. Data from one large study suggest that there is no significant difference in the rate of hospitalisations. Mortality was also lower with combined treatment (odds ratio 0.77; 95% confidence interval 0.63 to 0.94). Quality of life, lung function and withdrawals due to lack of efficacy favoured combination treatment. Adverse event profiles were similar between the two treatments. No significant differences were found between FPS and BDP in the primary outcomes, but the confidence intervals for the BDP results were wide as smaller numbers of patients have been studied.

Authors' conclusions:

Combination ICS and LABA significantly reduces morbidity and mortality in COPD when compared with monocomponent steroid. Adverse events were not significantly different between treatments, although evidence from other sources indicates that inhaled corticosteroids are associated with increased risk of pneumonia. Assessment of BDF in larger, long-term trials is required. Dose response data would provide valuable evidence on whether efficacy and safety outcomes are affected by different steroid loads.

This record should be cited as:

Nannini LJ, Cates CJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta-agonist in one inhaler versus inhaled steroids for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006826. DOI: 10.1002/14651858.CD006826

Assessed as up to date:

August 21, 2007

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Primary Review Group:

Airways Group

Health topics:

Lungs & airways > Chronic obstructive pulmonary disease (stable) > Bronchodilators

Lungs & airways > Chronic obstructive pulmonary disease (stable) > Combination/additive drug treatment

Lungs & airways > Chronic obstructive pulmonary disease (stable) > Corticosteroids (inhaled, oral or intranasal)

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Combination therapy of inhaled steroids and long-acting beta-agonists versus inhaled steroids alone

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