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Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease (Review)

Appleton S, Poole P, Smith B, Veale A, Lasserson TJ, Chan MMK, Cates CJ

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 1 http://www.thecochranelibrary.com

Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

[Intervention Review]

Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease


Sarah Appleton1 , Phillippa Poole2 , Brian Smith3 , Antony Veale4 , Toby J Lasserson5 , Matthew Ming Ki Chan6 , Christopher J Cates5
1 Dept.

of Medicine, The Queen Elizabeth Hospital, Woodville, Australia. 2 University of Auckland, Auckland, New Zealand.

3 Department of Medicine, University of Adelaide, Queen Elizabeth Hospital, Woodville, Australia. 4 Respiratory Medicine, The Queen

Elizabeth Hospital, Adelaide, Australia. 5 Community Health Sciences, St Georges, University of London, London, UK. 6 Adelaide University, Adelaide, Australia Contact address: Sarah Appleton, Dept. of Medicine, The Queen Elizabeth Hospital, Woodville Rd., Woodville, Adelaide, 5011, Australia. Sarah.Appleton@nwahs.sa.gov.au. Editorial group: Cochrane Airways Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009. Review content assessed as up-to-date: 22 March 2006. Citation: Appleton S, Poole P, Smith B, Veale A, Lasserson TJ, Chan MMK, Cates CJ. Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001104. DOI: 10.1002/14651858.CD001104.pub2. Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Chronic obstructive pulmonary disease (COPD) is characterised by partially reversible airow limitation. Many patients have little reversibility to short acting bronchodilators, but long acting bronchodilators are frequently advocated. Objectives To determine the effectiveness of long acting beta-2 adrenoceptor agonists (LABAs) in COPD patients demonstrating poor reversibility to short-acting bronchodilators. Search methods The Cochrane Airways Group Specialised Register was searched (all years to 2005) along with the reference lists from identied randomised controlled trials (RCTs). Selection criteria All RCTs comparing inhaled LABAs (salmeterol or formoterol) with placebo in the treatment of patients with stable, poorly reversible COPD. Studies were a minimum of four weeks in duration. Data collection and analysis Two authors independently performed data extraction and study quality assessment. If we required additional data, we contacted authors and pharmaceutical companies sponsoring the identied RCTs. Main results Twenty-three published and unpublished studies (6061 participants) were included in the review. There was a signicant change in forced expiratory volume in 1 second (FEV1) in favour of salmeterol 50 mcg twice daily (BID) of 51 mls (95% condence intervals (CI) 32 to 70), end of study morning peak expiratory ow (PEF) 14.89 L/min (95% CI 10.86 to 18.91). Supplemental shortLong-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

acting bronchodilator usage was reduced by just under one puff per day. There were signicant differences in the total, activity and impact domain scores of the St Georges respiratory questionnaire in favour of salmeterol 50 mcg BID. Findings from other health status measurements and symptom scores were conicting. There was no signicant difference in exercise tolerance. The number of participants experiencing exacerbations was signicantly reduced with salmeterol 50 mcg treatment compared with placebo (numbers needed to treat to benet 24). Authors conclusions This review shows that the treatment of patients with COPD with salmeterol 50 mcg produces modest increases in lung function. There were varying effects for other important outcomes such as health related quality of life or reduction in symptoms. However, there was a consistent reduction in exacerbations which may help people with COPD who suffer frequent deterioration of symptoms prompting healthcare utilisation. The strength of evidence for the use of salmeterol 100 mcg, formoterol 12 mcg, 18 mcg, 24 mcg was insufcient to provide clear indications for practice.

PLAIN LANGUAGE SUMMARY Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease This review aims to determine the effectiveness of long-acting beta-agonists, salmeterol or formoterol, in the treatment of COPD (emphysema/chronic bronchitis). These drugs improve airow in the lungs, and enable people with COPD to get on with their daily activities. Twenty-four studies (6061 participants) reported the effects of LABAs in people with COPD. People taking salmeterol 50 mcg daily do have fewer exacerbations than those on placebo, and some improvement in lung function and certain quality of life scores. The ndings were not consistent enough to support a general recommendation for the use of these drugs in the group of people with COPD with minimal variation in their lung function, although there is some evidence of improvement in important outcomes and these ndings require further exploration in additional trials.

Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.