Cochrane for Clinicians
Putting Evidence into Practice
Safety of Long-Acting Beta Agonists in Adults with Asthma
Am Fam Physician. 2014 Oct 1;90(7):453-454.
Author disclosure: No relevant financial affiliations.
Are long-acting beta agonists (LABAs), with or without inhaled corticosteroids, safe in the treatment of adult asthma?
LABAs appear to be safe when used with inhaled corticosteroids. LABA monotherapy is associated with an increase in asthma-related mortality and nonfatal serious adverse events, but not in all-cause mortality.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Asthma affects 8.2% of the U.S. population, and disproportionately affects those who are poor and black. Despite effective therapies, 3,404 U.S. deaths were attributed to asthma in 2010.1 Two types of inhaled pharmacologic agents are used for asthma control: inhaled corticosteroids and LABAs. Concerns about the safety of LABAs have risen with reports of increased hospital admissions and deaths.
This Cochrane review focused on LABA safety in adults with asthma. The authors included six previous reviews and five new randomized trials totaling 70,444 persons 12 years and older. There was no significant increase in all-cause mortality with LABA monotherapy compared with placebo (odds ratio [OR] = 1.37; 95% confidence interval [CI], 0.88 to 2.13; n = 33,952). However, asthma-related deaths were higher in those taking LABA monotherapy (OR = 3.54; 95% CI, 1.36 to 9.19; n = 33,313), and LABA monotherapy was associated with a small increase in nonfatal serious adverse events (i.e., events that are life-threatening, require hospitalization, or result in significant disability; OR = 1.14; 95% CI, 1.02 to 1.29; n = 35,954).
All-cause mortality did not increase among patients using LABA/inhaled corticosteroid combination therapy compared with those using inhaled corticosteroid monotherapy (OR = 1.42; 95% CI, 0.60 to 3.38; n = 24,718). Only one asthma-related death occurred among these patients. There was no significant increase in nonfatal serious adverse events in the LABA/inhaled corticosteroid group vs. the inhaled corticosteroid monotherapy group (OR = 1.07; 95% CI, 0.90 to 1.27; n = 24,718). Because of differing study methodologies, the authors were unable to compare deaths among patients on LABA monotherapy and those on LABA/inhaled corticosteroid combination therapy.
Multiple organizations have issued guidelines on the use of LABAs. The Department of Veterans Affairs/Department of Defense guidelines state that LABAs are contraindicated as monotherapy for maintenance treatment of asthma, but they do allow adding LABAs to an inhaled corticosteroid for persistent asthma.2 Similarly, the Institute for Clinical Systems Improvement states that after a patient starts a medium-dose inhaled corticosteroid, a LABA may be added to enhance control. It also recommends against the use of LABA monotherapy.3 The British Thoracic Society states that LABAs should be used only in patients already taking an inhaled corticosteroid.4 A prudent approach would be to use an inhaled corticosteroid as first-line treatment for patients with persistent asthma; LABAs are best reserved as adjunct treatment for those already taking an inhaled corticosteroid.
Cates CJ, et al. Safety of regular formoterol or salmeterol in adults with asthma: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2014;(2):CD010314.
The practice recommendations in this activity are available at http://summaries.cochrane.org/CD010314.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department, the Air Force Medical Service, the Uniformed Services University of the Health Sciences, or the Department of Defense at large.
REFERENCESshow all references
1. FastStats. Asthma. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/fastats/asthma.htm. Accessed May 4, 2014....
2. Management of Asthma Working Group. VA/DoD clinical practice guideline for management of asthma in children and adults. 2009. http://www.healthquality.va.gov/guidelines/CD/asthma/ast_2_full.pdf. Accessed May 8, 2014.
3. Sveum R, et al. Institute for Clinical Systems Improvement. Diagnosis and management of asthma. Updated July 2012. https://www.icsi.org/_asset/rsjvnd/Asthma.pdf. Accessed May 8, 2014.
4. British Guideline on the Management of Asthma. British Thoracic Society and Scottish Intercollegiate Guidelines Network. Revised January 2012. https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-guideline-on-the-management-of-asthma/. Accessed May 8, 2014.
These are summaries of reviews from the Cochrane Library.
The series coordinator for AFP is Corey D. Fogleman, MD, Lancaster General Hospital Family Medicine Residency, Lancaster, Pa.
A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.
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