LABA/LAMA Combination vs. Monotherapy

by Charles Vega, MD

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    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.

    About the Lecture

    The lecture LABA/LAMA Combination vs. Monotherapy by Charles Vega, MD is from the course Chronic Care.

    Included Quiz Questions

    1. ...improve FEV1.
    2. ...decrease mortality.
    3. ...decrease exacerbation rates.
    4. ...decrease symptom scores.
    5. ...have higher rates of adverse events.
    1. It is associated with decreased bone density when used for over 1 year.
    2. It can increase rates of pneumonia.
    3. It is associated with increased rates of oral candidiasis.
    4. It is best used in patients with moderate or severe COPD and a FEV1/FVC less than 60%
    5. It should be used in combination with long-acting beta agonists or long acting antimuscarinic agents.
    1. Start a long acting antimuscarinic agent (tiotropium) for COPD controller therapy.
    2. Start a beta-antagonist for better blood pressure control.
    3. Start an inhaled corticosteroid in addition to the combination albuterol-ipratropium that he is already using.
    4. Replace the albuterol-ipratropium with a long-acting beta agonist only.
    5. Start combination long acting beta-agonist and long acting antimuscarinic agent in addition to a short 3 day oral prednisone taper.

    Author of lecture LABA/LAMA Combination vs. Monotherapy

     Charles Vega, MD

    Charles Vega, MD

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