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Review: long acting β2-agonists and inhaled corticosteroids reduce exacerbations in chronic obstructive pulmonary disease
  1. P John Rees, MD
  1. Guy’s, King’s and St Thomas’ School of Medicine, London, UK

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 Q What are the effects of common treatments for chronic obstructive pulmonary disease (COPD) on patient outcomes?

    Clinical impact ratings GP/FP/Primary care ★★★★★☆☆ IM/Ambulatory care ★★★★★☆☆ Internal medicine ★★★★★☆☆ Respirology ★★★★★☆☆


    Embedded ImageData sources:

    Medline (1980 to 1 May 2002), Cochrane Database of Systematic Reviews, bibliographies of published articles, and experts.

    Embedded ImageStudy selection and assessment:

    English language randomised controlled trials with ⩾3 months of follow up in adults with COPD that assessed long acting (LA) β2 agonists (β2As); LA inhaled anticholinergics (tiotropium); combined short acting (SA) β2As and SA anticholinergics; inhaled corticosteroids; combined inhaled corticosteroids and LAβ2As; pulmonary rehabilitation (with ⩾6 wks follow up); long term nocturnal non-invasive mechanical ventilation; domiciliary O2 therapy; or disease management. Analysis was restricted to RCTs with blinded ascertainment of outcomes {only drug interventions}*, {>90%}* follow up data, and well balanced baseline characteristics in treatment and control groups.

    Embedded ImageOutcomes:

    COPD exacerbations and mortality.


    The results are summarised in the table.


    Long acting (LA) β2 agonists (β2As) and inhaled corticosteroids, with and without LAβ2As, reduce exacerbations but not mortality in patients with chronic obstructive pulmonary disease.

    Abstract and commentary also appear in ACP Journal Club and Evidence-Based Nursing.


    The review by Sin et al covers a wide range of treatments for COPD. Breadth is achieved at the expense of detail, but the authors provide a useful overview. A major criticism of respiratory medicine has been the absence of large, long term studies.

    In the controversial area of inhaled corticosteroid therapy for COPD, an attempt was made to rectify this paucity with several reasonably large studies that lasted ⩾3 years. These studies provided some important answers, but still left unanswered questions. 2 meta-analyses1,2 published in 2003 found a slower decline in FEV1 with inhaled corticosteroids compared with placebo, but the difference was <10 ml/y, and the authors came to opposite conclusions on the importance of the finding. These meta-analyses included more studies than the review by Sin et al, but the lack of available details makes comparisons difficult.

    Recent studies of COPD have concentrated on clinically relevant outcomes, such as exacerbations, quality of life, and admissions, although definitions of exacerbations vary. LAβ2As, tiotropium, and inhaled corticosteroids all reduce exacerbations by 20–30% relative to placebo. The added benefits of combination therapies on various endpoints are difficult to extricate and need further study. Corticosteroids seem to add to the effect of LAβ2As. The results provide a good case for LAβ2As or tiotropium in patients with more than mild COPD and inhaled corticosteroids in patients with more severe disease.

    Good evidence exists on the benefits of rehabilitation in the short to medium term, although there is uncertainty on how to maintain the initial benefit, and many countries have difficulty providing adequate respiratory rehabilitation programs. Smoking cessation and long term oxygen therapy are the only treatments that significantly improve the natural history and life expectancy of patients with COPD.

    New treatments may offer further benefits in COPD; this review provides a basis for optimal use of current treatments.


    Summary of efficacy data for interventions for chronic obstructive pulmonary disease*

 Q What are the effects of common treatments for chronic obstructive pulmonary disease (COPD) on patient outcomes?

    Clinical impact ratings GP/FP/Primary care ★★★★★☆☆ IM/Ambulatory care ★★★★★☆☆ Internal medicine ★★★★★☆☆ Respirology ★★★★★☆☆

    View Abstract


    • * Information provided by author.

    • For correspondence: Dr D D Sin, James Hogg iCAPTURE Center for Pulmonary and Cardiovascular Research, Vancouver, British Columbia, Canada.

    • Sources of funding: Canadian Institutes of Health Research and Alberta Heritage Foundation for Medical Research.

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