Medicine by the Numbers

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Combination LABA Inhalers Compared with High-Dose Inhaled Steroids for Adults with Asthma

 

Am Fam Physician. 2018 Mar 1;97(5):online.

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COMBINATION LONG-ACTING BETA AGONIST INHALERS FOR ADULTS WITH ASTHMA

BenefitsHarms

1 in 73 avioded a mild asthma attack

1 in 1,430 died because of an asthma attack

COMBINATION LONG-ACTING BETA AGONIST INHALERS FOR ADULTS WITH ASTHMA

BenefitsHarms

1 in 73 avioded a mild asthma attack

1 in 1,430 died because of an asthma attack

Details for This Review

Study Population: Adult patients of any age and sex with known asthma of differing severities, already receiving an inhaled steroid

Efficacy End Points: Mild asthma exacerbation/attacks (defined as taking oral steroids), severe attacks (leading to hospitalization), life-threatening attacks (requiring mechanical ventilation), asthma-related deaths, and overall deaths

Harm End Points: Death, asthma-related death, life-threatening asthma attack

Narrative: Long-acting beta agonists (LABAs) relax smooth muscle in asthmatic lungs, potentially preventing attacks and improving symptoms. Although inhaled steroids are the accepted first-line controller, adding LABAs is common. LABAs increase severe attacks and asthma deaths when used alone.1 This summary examines the effectiveness and safety of LABAs when combined with steroids. There are many LABA and LABA/steroid comparisons. We focused on trials addressing a common and relevant clinical dilemma among patients with asthma: When taking an inhaled steroid and seeking better control, should the steroid dose be increased or should a LABA/steroid combination be used?

The relevant Cochrane review examined 48 trials of more than 33,000 patients with asthma, assigning one group to a higher steroid dose and the other to a LABA/steroid. One in 73 patients in the LABA/steroid group avoided a mild attack (defined as requiring three to five days of oral steroids). However, adding a LABA did not reduce hospitalizations, deaths, or severe attacks. Moreover, for those with a 20% short-term risk of attack, one in 45 patients benefited; for those with a 1% risk of attack, one in 673 benefited. The more severe the asthma, the more likely the benefit. Adding a LABA also improved symptoms more than increasing the steroid dose, but at levels modest enough that asthma-related quality of life was unchanged.

Previous reviews have reached differing conclusions concerning safety. Two large reviews found that LABAs increase

Author disclosure: No relevant financial affiliations.


Copyright 2018 The NNT Group. Used with permission.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP Contributing Editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at http://www.aafp.org/afp/mbtn.

References

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2. Cates CJ, Cates MJ. Regular treatment with salmeterol for chronic asthma: serious adverse events. Cochrane Database Syst Rev. 2008;(3):CD006363.

3. Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE. Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths. Ann Intern Med. 2006;144(12):904–912.

4. Cates CJ, Wieland LS, Oleszczuk M, Kew KM. Safety of regular formoterol or salmeterol in adults with asthma: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2014;(2):CD010314.

5. Stempel DA, Raphiou IH, Kral KM, et al.; AUSTRI Investigators. Serious asthma events with fluticasone plus salmeterol versus fluticasone alone. N Engl J Med. 2016;374(19):1822–1830.

6. Chauhan BF, Ducharme FM. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev. 2014;(1):CD003137.

7. Kew KM, Evans DJ, Allison DE, Boyter AC. Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus addition of long-acting beta2-agonists (LABA) for adults with asthma. Cochrane Database Syst Rev. 2015;(6):CD011438.

 

 

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