NEW YORK (Reuters Health) – The benefit of adding inhaled corticosteroids to long-acting beta-2 agonists for treating chronic obstructive pulmonary disease (COPD) is limited, and furthermore, it’s accompanied by substantial risks of pneumonia and other infections.

Still, current guidelines recommend this combination for reducing exacerbations in patients with severe and very severe COPD, Dr. Gustavo J. Rodrigo, from Hospital Central de las Fuerzas Armadas in Montevideo, Uruguay, and his associates point out in the October issue of Chest.

In a large systematic review, Dr. Rodrigo and his colleagues compared the safety and efficacy of regular use of the two agents with use of long-acting beta-2 agonists alone.

Their literature search turned up 18 randomized controlled trials involving 12,446 stable patients with moderate-to-very severe COPD.

In the pooled analysis, combination therapy was associated with a significantly reduced risk of moderate COPD exacerbations compared with long-acting beta-2 agonists alone (17.5% vs 20.1%), with a number needed to treat of 31. Combined treatment had no effect on the incidence of severe COPD exacerbations, however.

Compared with the single-drug approach, the combination of drugs produced significantly greater improvements in pre- and post-bronchodilatory therapy FEV1, end-of-treatment dyspnea score, and health-related quality-of-life scores. The authors note, though, that “the size of these benefits did not reach the suggested clinically important minimal differences.”

The investigators also found that adding inhaled corticosteroids to the treatment regimen significantly increased patients’ relative risk of pneumonia (by 63%), viral respiratory infections (by 22%), and oropharyngeal candidiasis (by 59%). No associations were seen between groups in the rate of myocardial infarction.

Treatment with the long-acting beta-2 agonists/inhaled corticosteroid combination had no significant effect on overall mortality, respiratory mortality, or cardiovascular mortality.

Dr. Rodrigo and associates suggest, “It is likely that most patients with COPD with these levels of severity should be treated only with long-acting beta-2 agonist monotherapy,” at least until future research finds COPD phenotypes most likely to benefit from inhaled corticosteroids.

Reference:
Chest 2009;136:1029-1038.