So, that study would suggest that the
long-acting muscarinic antagonist (LAMA)
was superior to the long-acting beta agonist (LABA).
And this is a Cochrane review of
five different randomized trials
looking at that same issue – tiotropium
alone versus tiotropium plus a LABA.
And combination was slightly better for
health-related quality of life and FEV1.
So, adding the LABA to the LAMA
gives a mild improvement in symptoms and FEV1,
but it doesn't improve mortality,
the rate of exacerbations,
serious adverse events or study withdrawal.
So, therefore, maybe not worth it to add
a long-acting beta agonist to an
existing drug like tiotropium
for most patients because the
benefits aren't really that strong.
What about inhaled corticosteroids?
So, let’s go back to another Cochrane review.
So, this is 55 randomized trials of patients with COPD,
over 16,000 participants.
The main improvement is a moderate reduction
in the number of exacerbations per year
and a slower reduction in quality of life
among patients who take corticosteroids.
The improvement in FEV1 is pretty
questionable with inhaled corticosteroids.
And really, these drugs,
inhaled corticosteroids, are most effective
for patients with moderate to severe COPD,
not for patients with mild COPD.
No, they don’t improve mortality.
There is some risk of oral candidiasis
and a higher risk of pneumonia in these studies as well.
But the inhaled corticosteroids
had no negative effects on bone
after following up for three years of use.
So, let's look at what the global initiative
says in terms of recommendations.
So, for short acting drugs,
they don't really prefer a beta agonist
versus an anti-muscarinic agent,
but they note that long-acting drugs,
either a LABA or a LAMA
are better for symptom relief.
So, try to use long-acting drugs for control.
Bronchodilators, they are long-acting.
Also reduce the risk of exacerbation,
hospitalization and they improve quality of life.
They conclude that that LABA/LAMA
combination is probably better
than just increasing the single agent alone.
For me, I start with that long-acting
muscarinic antagonist, the LAMA.
And if the patient is not doing well enough on that,
I will add the LABA on top of it in combination.
As I mentioned, the inhaled corticosteroids
can reduce the risk of exacerbation,
particularly among those with a low FEV1.
And they felt like they were more positive overall
on the use of inhaled corticosteroids compared with Cochrane.
So, they wanted them used more broadly
even though they only have moderate effects
in reducing the risk of exacerbation.
They should not be used alone, though.
So, if they're used,
inhaled corticosteroids should only be used
when combined with a LABA or a LAMA.
All right. That was a lot to get through.
But the take-home messages are,
make sure these patients get spirometry,
differentiate asthma from COPD
with the understanding that there can be
some component of both in many patients.
Quitting smoking at any stage of COPD
before diagnosis or after diagnosis is absolutely critical.
And think about using these
long-acting muscarinic antagonists.
They seem to be slightly superior,
but they can be combined with LABAs,
they can be combined with inhaled corticosteroids
among patients with more severe COPD.
Thanks very much.