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Reference: JAMA 2014 Sep 17;312(11):1114 (level 2 [mid-level] evidence)
Chronic obstructive pulmonary disease (COPD) is a major public health problem, currently affecting 210 million people worldwide and projected to be the fourth leading cause of death by 2030 (WHO 2007 PDF). Although no existing COPD medication has been shown to modify long-term lung function, pharmacological interventions such as long-acting beta-agonists (LABAs) and inhaled corticosteroids are routinely used to manage symptoms and complications (GOLD 2013 Feb 13 PDF). A recent Cochrane review of randomized trials found LABAs plus inhaled corticosteroids reduced COPD exacerbations more than LABAs alone, although results on mortality were inconsistent (Cochrane Database Syst Rev 2012 Sep 12;(9):CD006829). A recent Cochrane review of randomized trials found LABAs plus inhaled corticosteroids reduced COPD exacerbations more than LABAs alone, although results on mortality were inconsistent (Cochrane Database Syst Rev 2012 Sep 12;(9):CD006829).
Now, a population-based cohort study investigated COPD hospitalizations and death in 11,872 propensity-matched elderly patients (> 66 years old) with COPD newly prescribed LABAs plus inhaled corticosteroids or LABAs alone. A cohort of 3,160 patients taking LABAs alone were matched with 8,712 patients taking combination therapy based on a propensity score, age, sex, asthma codiagnosis, and COPD duration. Patients were followed for about two and a half years. Compared to LABAs alone, LABAs plus inhaled corticosteroids were associated with a small, but statistically significant, reduction in mortality (55.3% vs. 58.6%, p < 0.001, NNT 31) and COPD hospitalizations (27.8% vs. 30.1%p < 0.001, NNT 44). No significant differences in hospitalizations for pneumonia or fragility fracture were observed.
The results of this large population-based study extend the results of previous randomized trials, showing that the addition of inhaled corticosteroids to LABAs not only decreases the frequency of COPD exacerbations, but may also decrease COPD-related hospitalizations and mortality. The patient population examined in this study matches the patients expected in clinical practice, particularly the inclusion of elderly patients and those with asthma and other comorbidities. However, these findings are limited by the observational design of the study, and a randomized trial would be optimal for confirming these findings.
For more information see the Inhaled corticosteroids for COPD and Bronchodilators for COPD topics in DynaMed.