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Combination long-acting beta-agonists and inhaled corticosteroids versus long-acting beta-agonists alone in older adults with chronic obstructive pulmonary disease

Gershon AS, Campitelli MA, Croxford R, Stanbrook MB, To T, Upshur R, Stephenson A, Stukel TA. JAMA. 2014; 312(11):1114-21. Epub 2014 Sep 17.


Importance — Chronic obstructive pulmonary disease (COPD), a manageable respiratory condition, is the third leading cause of death worldwide. Knowing which prescription medications are the most effective in improving health outcomes for people with COPD is essential to maximizing health outcomes.

Objective — To estimate the long term benefits of inhaled combination long-acting beta-agonists (LABA) and inhaled corticosteroids (ICS) compared with LABA alone in a real-world setting.

Design, Setting and Patients — A population-based, longitudinal cohort study set in Ontario, Canada from 2003 to 2011.  All individuals aged 66 years and older who met a validated case definition of COPD on the basis of health administrative data were included.

Exposure — Newly prescribed combination LABA and ICS or LABA alone.

Main Outcome — The composite outcome of death and COPD hospitalization. 

Results — After propensity-score matching, there were 8,712 new users of LABA and ICS combination therapy and 3,160 new users of LABA who were followed for median times of 2.7 years and 2.5 years, respectively. The main outcome was observed among 5594 new users of LABA and ICS (3174 deaths [36.4%]; 2420 COPD hospitalizations [27.8%]) and 2129 new users of LABA (1179 deaths [37.3%]; 950 COPD hosptializations [30.1%]). New use of LABA and ICS was associated with a modestly reduced risk of death or COPD hospitalization compared with new use of LABA (difference in composite at five years -3.7%, 95% confidence interval -5.7% to -1.7%; hazard ratio [HR], 0.92; 95% CI, 0.88-0.96). The greatest difference was among COPD patients with a co-diagnosis of asthma (difference in composite at five years -6.5%, 95% confidence interval -10.3 to -2.7; HR, 0.84, 95% CI, 0.77-0.91) and those who were not receiving inhaled long-acting anti-cholinergic (LAA) medication (difference in composite at five years -8.4%, 95% confidence interval -11.9 to -4.9; HR, 0.79, 95% CI, 0.73-0.86).

Conclusions and Relevance — Newly prescribed LABA and ICS combination therapy in older COPD patients, particularly those with asthma and those not receiving a LAA, was associated with a significantly lower risk of the composite outcome of death or COPD hospitalization compared to newly prescribed LABA alone.

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Keywords: Asthma Chronic diseases and conditions Chronic obstructive pulmonary disease

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