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Combined inhalers cut COPD deaths

Combined inhaler treatment for COPD reduces mortality, according to a new review, but GPs remain concerned about side-effects.

The Cochrane review com-bined data from the TORCH study – the only major trial looking at the effect of a combined inhaled steroid and long-acting beta-agonist treatment on death – with other studies.

When taken together, salmeterol/fluticasone propionate significantly reduced the number of deaths in patients with COPD by 33% compared with fluticasone alone, and by 21% compared with placebo.

Dr Kevin Gruffydd-Jones, a GP in Wiltshire and member of the General Practice Airways Group, said this confirms that combination inhalers reduce exacerbations and ‘probably' mortality in patients with moderate to severe COPD.

‘There is an increased risk of pneumonia and other relatively minor adverse effects, but the benefits outweigh the risks,' he said.

NICE currently recommend combination treatment for patients with compromised lung function or who have had two or more exacerbations requiring treatment in the past year.

But Dr Dermot Ryan, a GP in Loughborough and member of the General Practice Airways Group, warned that there remained a question about the optimum dose of inhaled corticosteroids in COPD.

‘A lower dose of inhaled corticosteroids might lead to a smaller risk of pneumonia and other long-term side effects … not addressed in these reviews largely because, apart from Isolde, they were all short term studies of one year or less.'

Professor Sebastian Johnston at the National Heart and Lung Institute, was not surprised at the results. ‘These results suggest some effect, but you really need another TORCH to look at this.'

What works in COPD

What works in COPD

What works in COPD

- a fixed dose ster-oid/LABA inhaler in stable moderate to severe disease re-duces exacerbations compared to placebo or an inhaled steroid
- using a combination inhaler on its own in unstable COPD is 'inappropriate'
- more research is needed before firm recommendations on doses can be made

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