Wednesday, September 17, 2008

Good News for COPD

A recent study in the Annals of Internal Medicine linked an older drug used for COPD (ipratropium) to deaths in patients with COPD (chronic obstructive pulmonary disease or emphysema). ABC News reported Older Emphysema Drug Linked to Heart Deaths, which initially sounds like bad news, but actually the study's findings (which barely got any press) were actually very good news. The study looked at data from the U.S. Veterans Health Administration health care system and compared patients respiratory medicines for patients who had died to patients who were living. They did find that death rate was significantly higher (11%) for patients taking ipratropium, and older, short acting inhaler for COPD. However, they also found a 20% lower risk of death for patients on inhaled steroids and an 8% lower risk of death for patients on long acting β-agonists. This data is consistent with recent prospective studies looking at combination of long acting β-agonists and inhaled steroids which found that they reduced exacerbations and may have decreased death. A recent analysis of this study showed that this combination also prevented the decline in lung function seen with COPD. This is now the only report of a medication that has been able to show this, as the only other method to prevent decline in lung function is smoking cessation. There was also another comparison of long acting β-agonists and inhaled steroids (Advair) vs. tiotropium (Spiriva) which found no difference in exacerbations, but a lower rate of death in the Advair group.

All of this combined makes medical sense. First, ipratropium is a short acting bronchodilator. When used alone, it is supposed to be taken 4 times a day but is often taken as needed. Thus, it makes sense that patients with lung disease might do poorly on this. Having long acting medicines on board likely improves control of the lung disease thereby preventing death. Secondly, COPD has a component of inflammation, so using anti-inflammatory medications has benefit. Not only are exacerbations lower, but this seems to prevent death. Taken together this suggests that patients with COPD should be on a combination of a long acting bronchodilator to control their symptoms and an inhaled steroid to prevent exacerbations, prevent decline in lung function and reduce their chance of dying.

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