P5.2 Comparison of inhaled medications

A systematic review examined the relative effectiveness of inhaled medications to reduce the risk of exacerbations of COPD (Puhan 2009a). The authors identified 35 randomised controlled trials of at least 4 weeks duration that enrolled 26,786 patients with COPD of whom 27% had one or more exacerbations. All regimes significantly reduced the odds of exacerbation compared with placebo – no single inhaled medication was more effective than another. If FEV1 was ≤ 40% predicted, long acting antimuscarinics, inhaled corticosteroids and combination treatment reduced exacerbations significantly compared with long-acting beta agonists alone. However the authors did not have FEV1 data for individual patients.

In 2012, Chong et al (Chong 2012) performed a meta-analysis that compared tiotropium to a range a long acting beta-agonists, data from over 11,000 patients were included and trials were at least 3 months long. Chong reported that tiotropium was more effective in preventing COPD exacerbations leading to hospitalisation (odds ratio 0.86; 95% CI 0.79 to 0.93). There was no difference in mortality, all-cause hospitalisations, quality of life and lung function. There were fewer serious adverse events with tiotropium (OR 0.88; 95% CI 0.78 to 0.99).