Drugs for COPD: current evidence

Abstract

EditorialR ecent evidence provides greater clarity on drug treatment choices in COPD. Treatment for COPD is focussed on minimising risk factors, improving symptoms, and preventing exacerbations. With the exception of smoking-cessation programmes for patients with early disease, home oxygen treatment for persistent hypoxaemia and lung-reduction surgery for selected patients with emphysema, no treatment has been shown to reduce mortality. Inhaled corticosteroidsPulmonary inflammation is prominent in COPD but inhaled corticosteroids (ICS) have not been shown to reduce the rate of decline of lung function. In a retrospective analysis, 1 ICS have been reported to reduce COPD-related mortality but this claim has been challenged by other analyses. 2,3 A double-blind, placebo-controlled trial designed to assess the effect of inhaled drugs on overall mortality has now been published. 4 The TOwards a Revolution in COPD Health (TORCH) study compared Seretide (salmeterol and fluticasone) with fluticasone alone (Flixotide), salmeterol alone (Serevent) and placebo over a three-year period. The risk of death in the Seretide, fluticasone and salmeterol groups did not differ significantly from that in the placebo group. Worryingly, the probability of having pneumonia was significantly greater in the fluticasone and Seretide groups than in the salmeterol or placebo groups, with a number needed to harm (NNH) of around 17.Some other recent evidence also suggests an increased risk of pneumonia with ICS use in COPD. 5 A nested case-control study found the use of ICS to be associated with an excess risk of pneumonia hospitalisation and of pneumonia hospitalisation leading to death within 30 days among older patients with COPD. The rate ratio for hospitalisation was greatest with the highest doses of ICS (equivalent to fluticasone 1000µg per day or more). ExacerbationsA subgroup analysis of the Inhaled Steroids in Obstructive Lung Disease in Europe (ISOLDE) study suggested that ICS might have benefit in reducing exacerbations by about 25 per cent. 6 This is somewhat difficult to interpret as 57 per cent of those allocated placebo had been using regular ICS and these were withdrawn before randomisation. Did this contribute to the exacerbation rate? Combination inhalersAlthough ICS alone are not licensed for use in COPD, the National Institute for Health and Clinical Excellence (NICE) recommends them as an option in more severe COPD with frequent exacerbations. 7 Combination inhalers containing ICS and a long-acting beta-agonist (LABA) are being increasingly prescribed. Does the combination add any extra benefit?The TRial of Inhaled STeroids ANd long-acting beta 2 -agonists (TRISTAN) compared Seretide with fluticasone alone, salmeterol alone and placebo. 8 Although Seretide reduced the rate of exacerbations by about 30 per cent compared to placebo, it was no different to fluticasone or salmeterol alone. It is also worth noting that in this trial 52 per cent of placebo patients had been using ICS and 38 per cent LABA before enrolment and ...