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.