Is the Combination of ICS and LABA, a Therapeutic Option for COPD, Fading Away?

The combination of an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA) has been one of the most popular options for the treatment of stable chronic obstructive pulmonary disease (COPD). Ten years ago, the combination of ICS/LABA was firstly proven to have beneficial effects for COPD on respiratory symptom, lung function, health-related quality of life, and exacerbation in a large multicenter randomized controlled trial1. After the trial, the combination of ICS/LABA has become one of the most important therapeutic options for the treatment of stable COPD and has been increasingly prescribed until recently.

However, a series of publications suggest that a long-acting muscarinic antagonist (LAMA), either alone or in the combination with a LABA, is a preferred therapeutic option in comparison to the combination of ICS/LABA because of better clinical efficacy and less adverse effect234. So, the document, GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD, the combination of ICS/LABA is not recommended as the first line therapeutic option any more5.

A recent study proved that a dual bronchodilator of LABA/LAMA is superior to the combination of ICS/LABA because the group of COPD patients treated with the dual bronchodilator resulted in better clinical outcomes of less exacerbation, better lung function, better health-related quality of life and also in less adverse effect of pneumonia. Compared to the combination of ICS/LABA, even a LAMA alone has a comparable efficacy without any increase of pneumonia risk3. The combination of ICS/LABA has raised the issue of pneumonia since the clinical trial of TORCH1. For the patients with COPD, the component of ICS among ICS/LABA increases the risk of pneumonia although most of the studies have pointed out fluticasone propionate, a potent ICS, as the culprit6.

However, the combination of ICS/LABA still has a role in the treatment of COPD. In case of asthma COPD overlap syndrome (ACOS), the combination of ICS/LABA is the most suitable therapeutic option because the component ICS should be needed for the treatment of the component, asthma among ACOS7. The triple combination of ICS/LABA/LAMA may be prescribed for the treatment of COPD patients who exacerbates frequently despite the treatment of a dual bronchodilator.

Now it is the time that we should consider the next revision of the Korean COPD guidelines, which has been updated in 2014. The next revision should comprise these changes in the therapeutic options mentioned above on the basis of the recent publications.