LABA/LAMA Combination vs. Monotherapy

00:01 So, that study would suggest that the long-acting muscarinic antagonist (LAMA) was superior to the long-acting beta agonist (LABA).

00:10 And this is a Cochrane review of five different randomized trials looking at that same issue – tiotropium alone versus tiotropium plus a LABA.

00:21 And combination was slightly better for health-related quality of life and FEV1.

00:25 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, symptom scores, serious adverse events or study withdrawal.

00:42 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.

00:55 What about inhaled corticosteroids? So, let’s go back to another Cochrane review.

00:59 So, this is 55 randomized trials of patients with COPD, over 16,000 participants.

01:05 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.

01:16 The improvement in FEV1 is pretty questionable with inhaled corticosteroids.

01:22 And really, these drugs, inhaled corticosteroids, are most effective for patients with moderate to severe COPD, not for patients with mild COPD.

01:30 No, they don’t improve mortality.

01:32 There is some risk of oral candidiasis and a higher risk of pneumonia in these studies as well.

01:39 But the inhaled corticosteroids had no negative effects on bone after following up for three years of use.

01:47 So, let's look at what the global initiative says in terms of recommendations.

01:52 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.

02:09 So, try to use long-acting drugs for control.

02:14 Bronchodilators, they are long-acting.

02:16 Also reduce the risk of exacerbation, hospitalization and they improve quality of life.

02:22 They conclude that that LABA/LAMA combination is probably better than just increasing the single agent alone.

02:29 For me, I start with that long-acting muscarinic antagonist, the LAMA.

02:36 And if the patient is not doing well enough on that, I will add the LABA on top of it in combination.

02:44 As I mentioned, the inhaled corticosteroids can reduce the risk of exacerbation, particularly among those with a low FEV1.

02:54 And they felt like they were more positive overall on the use of inhaled corticosteroids compared with Cochrane.

03:03 So, they wanted them used more broadly even though they only have moderate effects in reducing the risk of exacerbation.

03:10 They should not be used alone, though.

03:12 So, if they're used, inhaled corticosteroids should only be used when combined with a LABA or a LAMA.

03:20 All right. That was a lot to get through.

03:22 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.

03:34 Quitting smoking at any stage of COPD before diagnosis or after diagnosis is absolutely critical.

03:42 And think about using these long-acting muscarinic antagonists.

03:47 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.

03:58 Thanks very much.