Combined corticosteroid and long‐acting beta2‐agonist in one inhaler versus long‐acting beta2‐agonists for chronic obstructive pulmonary disease

• Published in: Cochrane database of systematic reviews 2012-09, Vol.2012 (9)
• Main Authors: Nannini, Luis Javier, Lasserson, Toby J, Poole, Phillippa
• Format: Article
• Language: English
• Subjects: Medicine General & Introductory Medical Sciences
• ISSN: 1469-493X
• DOI: 10.1002/14651858.CD006829.pub2

Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema. People with COPD have damaged (inflamed) or narrowed airways (tubes in the lungs), which makes breathing difficult. The symptoms are breathlessness, coughing and phlegm and can vary from mild to severe (where day‐to‐day activities become limited). The most common cause of COPD is smoking, however COPD may also be caused by occupational exposure to dust. This review is about regular treatment with the combined delivery of inhaled steroids and long‐acting beta agonists in one inhaler (a combination inhaler). Combination inhalers contain two medications normally given in separate inhalers, a long‐acting beta 2 ‐agonist (LABA), which is a bronchodilator that widens the tubes in the lungs, and a steroid which helps control the underlying inflammation in the lungs. This combination inhaler may make it easier to take the medication than using separate inhalers. Two combination inhalers containing two different medications are currently licensed for COPD, budesonide and formoterol (marketed as Symbicort) and fluticasone and salmeterol (marketed as Advair, Viani or Seretide). We searched for randomised controlled trials (RCTs) that compared any combination inhaler versus the same LABA component inhaler used by people with COPD. The studies were well‐designed with low risk of bias for randomisation and blinding but there were high numbers of people who dropped out of the trials, which affected our confidence in the results for the outcomes. Overall, we found 14 trials involving 11,794 people with COPD. The results of the studies showed that combined inhalers reduced the frequency of exacerbations compared with their LABA component alone, from, for example, an average of one exacerbation per year on a long‐acting beta 2 ‐agonist to an average of 0.76 exacerbations per year on a combined inhaler. The risk of mortality was similar between the treatments, although the overall result was not precise enough to rule out an effect in favour of either treatment. There was evidence of an overall increased risk of pneumonia with combined inhalers, from around three per 100 people per year on LABA to four per 100 per year on combined inhalers. There was no significant difference between treatments in terms of hospitalisations although the results of the three studies were inconsistent so we cannot be certain what this means. Combined treatment was more effective than LABA in improving health