Reducing the risk of exacerbations in patients with severe COPD

Does adding an inhaled corticosteroid to treatment with a long-acting ß₂-agonist help prevent exacerbations of chronic obstructive pulmonary disease (COPD)? According to Kardos and associates, the answer is yes.

The authors studied 994 patients with severe COPD who were clinically stable. The patients were randomly assigned to receive a salmeterol/fluticasone combination or salmeterol alone for 44 weeks.

Fewer exacerbations occurred in patients who received the salmeterol/fluticasone combination than in those who received salmeterol alone (334 versus 464; P < .0001). The annualized rate of moderate and severe exacerbations per patient was 35% lower in the group that received combination therapy. This group also had a longer mean time to first exacerbation. Other benefits associated with the salmeterol/fluticasone combination included a decreased use of rescue medication and a better health- related quality of life.

The 2 groups did not differ with respect to the incidence of adverse events. However, pneumonia was more likely to occur among those who received the salmeterol/fluticasone combination.

In an accompanying editorial, Niewoehner and Wilt review the controversy surrounding the use of inhaled corticosteroids in patients with COPD, which includes debate about their effectiveness in this setting and concerns about adverse effects. They note that the dosage of fluticasone used in the above- described study was relatively high (500 µg twice daily) and that given the immunosuppressive effects of corticosteroids, the increased rate of pneumonia is not very surprising.

Niewoehner and Wilt conclude that the combination of an inhaled corticosteroid and a long-acting ß₂-agonist is most likely to be beneficial in exacerbation-prone patients who have severe COPD.