Does Adding LABA/ICS to Tiotropium Improve COPD Outcomes?
A Cochrane systematic review has found new moderate-quality evidence that tiotropium + long-acting beta2-agonist/inhaled corticosteroid (LABA/ICS) combination therapy reduces hospital admission for COPD patients, compared with tiotropium + placebo.
Tiotropium, a long-acting bronchodilator, and single-inhaler LABA/ICS combination therapy are often used as maintenance treatment in patients with chronic obstructive pulmonary disease (COPD). Maria Ximena Rojas-Reyes, from Pontificia Universidad Javeriana, Bogota, DC, Colombia, and colleagues explored whether combining these treatments could be more effective than its separate components. They assessed relative effects of tiotropium + LABA/ICS vs. tiotropium, and tiotropium + LABA/ICS vs. LABA/ICS regarding exacerbations, symptoms, quality of life, and lung function in patients with COPD.
Study authors searched the Cochrane Airways Group Specialised Register of Trials and the World Health Organization (WHO) trials to include parallel, randomized-controlled with a duration of ≥3 months that compared ICS and LABA combination therapy in addition to tiotropium vs. tiotropium alone or combination therapy alone. A total of 6 studies (n=1,902) were included for the analysis, all of which compared tiotropium + ICS/LABA therapy vs. tiotropium alone.
Rojas-Reyes and her team found no statistically significant differences in mortality between treatments (odds ratio [OR] 1.80, 95% CI: 0.55–0.91) and a reduction in all-cause hospitalizations with tiotropium + LABA/ICS (OR 0.61, 95% CI: 0.40–0.92). According to the St. George's Respiratory Questionnaire (SGRQ), a statistically significant improvement in total score with the use of tiotropium + LABA/ICS vs. tiotropium alone was seen (mean difference [MD] –3.46, 95% CI: –5.05 to –1.87) regarding quality of life. Also, lung function significantly differed in the tiotropium + LABA/ICS group "although the average benefit with this therapy was small." Investigators observed no statistically significant difference in adverse events, serious adverse events, and pneumonia.
One of the 6 studies also compared also evaluated tiotropium + LABA/ICS vs. LABA/ICS alone. Due to lack of power, the results did not allow for a conclusion to be drawn.
Overall, moderate-quality evidence indicated that tiotropium + LABA/ICS vs. tiotropium + placebo decreased hospital admission. Low-quality evidence suggested an improvement in disease-specific quality of life with tiotropium + LABA/ICS therapy. Evidence is lacking, however, to support the combination therapy for mortality (moderate-quality evidence) and exacerbations (low-quality evidence). Tiotropium + LABA/ICS did not increase adverse events or serious non-fatal adverse events when compared with tiotropium + placebo, study authors added.
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