This article is a transcript of a monthly podcast hosted by Neil Skolnik, MD, that covers the most practice-changing articles from the last month. Listen to the streaming version on Univadis.
Neil Skolnik, MD: Hello, I’m Dr. Neil Skolnik, Professor of Family and Community Medicine at Sidney Kimmel Medical College, Thomas Jefferson University, and Associate Director of the Family Medicine Residency Program at Abington Jefferson Health.
An important clinical question in primary care over the last 2-3 years is what should be the primary therapy for patients with severe COPD. The current study, "Indacaterol/glycopyrronium Versus Salmeterol/fluticasone in the Prevention of Clinically Important Deterioration in COPD: A Sub-analysis From the FLAME Study," published in Respiratory Research, helps address this question.
Essentially, the authors found, in a very large study, that indacaterol/glycopyrronium significantly delayed the time to clinically important deterioration by 28% with a very significant P value and reduced the incidence of clinically important deterioration vs salmeterol/fluticasone. Additionally, that same result was found in all patient subgroups.
Why this matters
Until recently, ICS/LABA therapy (an inhaled steroid and a long-acting beta agonist) was considered the unquestioned approach to moderate to severe COPD. Then a number of studies, including the FLAME trial, were published showing better bronchodilator effect with dual bronchodilator therapy, a LAMA/LABA (a long-acting muscarinic antagonist and a LABA), than with inhaled steroid/LABA therapy.
The FLAME trial also showed better bronchodilation and fewer exacerbations with dual bronchodilator therapy than with ICS/LABAs. In addition, studies showed that patients who received an inhaled steroid had a higher incidence of pneumonia. This led the GOLD guidelines, a year ago in the fall of 2017, to recommend LAMA/LABA dual bronchodilator therapy as first-line treatment for patients with moderate to severe COPD.
This current post hoc analysis of the FLAME trial, using clinically important deteriorations, again shows the benefit of LAMA/LABAs over ICS/LABAs. Remember, though, that the recent IMPACT trial compared triple therapy (an ICS/LABA and a LAMA) to dual bronchodilator therapy and showed a 25% decrease in moderate to severe exacerbations, as well as a 34% decrease in severe exacerbations leading to hospitalizations.
So, what do we do with all that information? I think we really let the people who analyze the data carefully guide us with their recommendations. So the current GOLD guidelines say that for patients with moderate to severe COPD, the primary therapy is dual bronchodilator therapy (a LABA/LAMA) and then, for patients who are continuing to have exacerbations, add an inhaled corticosteroid.
Whether or not the IMPACT study changes those recommendations over the coming year is to be determined. And we’ll see what the GOLD guidelines say when they come out late this year. But for now, we’ll stay with the current guidelines. And the FLAME study, in particular, this subanalysis looking at clinically important deteriorations, clearly shows that for patients with moderate to severe COPD, dual bronchodilator therapy shows a favorable decrease in clinically important deteriorations and exacerbations when compared to an ICS/LABA.
Listen to the streaming version on Univadis.