BACKGROUND: Guidelines recommend the use of inhaled long-acting bronchodilators, inhaled corticosteroids (ICS) and their combinations for maintenance treatment of moderate to severe COPD. However, there are limited data supporting combination therapy. METHODS: This systematic review assessed the efficacy of three therapeutic approaches: tiotropium plus long-acting beta2-agonist (LABA) ("dual" therapy), LABA/ICS ("combined" therapy), and tiotropium plus LABA/ICS ("triple" therapy), all compared with tiotropium monotherapy. Randomized controlled trials were identified after a search of different databases of published and unpublished trials. RESULTS: Twenty trials (6803 participants) were included. "Dual" therapy showed significant improvements in forced volume in the first second (FEV(1)), health-related quality of life (HRQoL), and dyspnea. However, it failed to reduce the risk of COPD exacerbations. Compared with tiotropium, "combined" therapy presented modest but significant effects on FEV(1), HRQoL, and dyspnea. Again, there was no significant difference in exacerbations, but it was associated with a significant increase of serious adverse effects (SAE) (number need to treat for harm [NNTH] = 20; 95% CI: 11-119). Finally, "triple therapy" increased FEV(1), improved HRQoL (both benefits exceeded minimal important differences) and decrease COPD exacerbations in anon-significant way. (Odds ratio [OR] = 0.57; 95% CI: 0.24 to 1.37, p = 0.21). CONCLUSIONS: "Dual" and "triple" therapy seem like the most promising for patients with moderate to very severe COPD. However, data are still scarce and studies too short to generate a strong recommendation. Future studies should examine long-term efficacy and safety. Copyright Â
BACKGROUND: Guidelines recommend the use of inhaled long-acting bronchodilators, inhaled corticosteroids (ICS) and their combinations for maintenance treatment of moderate to severe COPD. However, there are limited data supporting combination therapy. METHODS: This systematic review assessed the efficacy of three therapeutic approaches: tiotropium plus long-acting beta2-agonist (LABA) ("dual" therapy), LABA/ICS ("combined" therapy), and tiotropium plus LABA/ICS ("triple" therapy), all compared with tiotropium monotherapy. Randomized controlled trials were identified after a search of different databases of published and unpublished trials. RESULTS: Twenty trials (6803 participants) were included. "Dual" therapy showed significant improvements in forced volume in the first second (FEV(1)), health-related quality of life (HRQoL), and dyspnea. However, it failed to reduce the risk of COPD exacerbations. Compared with tiotropium, "combined" therapy presented modest but significant effects on FEV(1), HRQoL, and dyspnea. Again, there was no significant difference in exacerbations, but it was associated with a significant increase of serious adverse effects (SAE) (number need to treat for harm [NNTH] = 20; 95% CI: 11-119). Finally, "triple therapy" increased FEV(1), improved HRQoL (both benefits exceeded minimal important differences) and decrease COPD exacerbations in anon-significant way. (Odds ratio [OR] = 0.57; 95% CI: 0.24 to 1.37, p = 0.21). CONCLUSIONS: "Dual" and "triple" therapy seem like the most promising for patients with moderate to very severe COPD. However, data are still scarce and studies too short to generate a strong recommendation. Future studies should examine long-term efficacy and safety. Copyright Â
Authors: Gerard J Criner; Jean Bourbeau; Rebecca L Diekemper; Daniel R Ouellette; Donna Goodridge; Paul Hernandez; Kristen Curren; Meyer S Balter; Mohit Bhutani; Pat G Camp; Bartolome R Celli; Gail Dechman; Mark T Dransfield; Stanley B Fiel; Marilyn G Foreman; Nicola A Hanania; Belinda K Ireland; Nathaniel Marchetti; Darcy D Marciniuk; Richard A Mularski; Joseph Ornelas; Jeremy D Road; Michael K Stickland Journal: Chest Date: 2015-04 Impact factor: 9.410
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Authors: Frederico Leon Arrabal Fernandes; Alberto Cukier; Aquiles Assunção Camelier; Carlos Cezar Fritscher; Cláudia Henrique da Costa; Eanes Delgado Barros Pereira; Irma Godoy; José Eduardo Delfini Cançado; José Gustavo Romaldini; Jose Miguel Chatkin; José Roberto Jardim; Marcelo Fouad Rabahi; Maria Cecília Nieves Maiorano de Nucci; Maria da Penha Uchoa Sales; Maria Vera Cruz de Oliveira Castellano; Miguel Abidon Aidé; Paulo José Zimermann Teixeira; Renato Maciel; Ricardo de Amorim Corrêa; Roberto Stirbulov; Rodrigo Abensur Athanazio; Rodrigo Russo; Suzana Tanni Minamoto; Fernando Luiz Cavalcanti Lundgren Journal: J Bras Pneumol Date: 2017 Jul-Aug Impact factor: 2.624