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Am Fam Physician. 2010;81(1):68

Background: Current guidelines recommend combining inhaled corticosteroids with long-acting beta agonists to treat symptomatic patients with severe or very severe (stage III or IV) chronic obstructive pulmonary disease (COPD). However, there is conflicting evidence as to whether a combination of inhaled corticosteroids and long-acting beta agonists is superior to beta-agonist therapy alone.

The Study: Rodrigo and colleagues conducted a review of randomized controlled trials (RCTs) of stable patients who had COPD treated with inhaled corticosteroids (fluticasone [Flovent], budesonide [Rhinocort], or beclomethasone) and long-acting beta agonists (salmeterol [Serevent] or formoterol [Foradil]). Eligible studies compared combination therapy to beta-agonist monotherapy. Primary outcomes included moderate to severe COPD exacerbations, and cardiovascular, respiratory, or all-cause mortality.

Results: The authors reviewed 18 RCTs involving 12,446 participants. The combination therapy improved forced expiratory volume in one second and reduced the development of moderate COPD exacerbations (number needed to treat = 31) compared with long-acting beta-agonist monotherapy, but there was not a significant reduction in severe COPD exacerbations or mortality rates. Patients using combination therapy were more likely to develop pneumonia, oral candidiasis, and viral respiratory infections (relative risks = 1.63, 1.59, and 1.22, respectively), but no difference in the rate of myocardial infarctions was observed.

Conclusion: The combination of inhaled corticosteroids and long-acting beta agonists significantly reduced the number of moderate COPD exacerbations (although the number of severe exacerbations was not reduced), but increased the risk of secondary infections. No improvement in mortality was seen. Despite current guideline recommendations, the authors recommend treatment with long-acting beta-agonist monotherapy.

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