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Anticholinergic bronchodilators, long acting β2 agonists, and inhaled corticosteroids are the mainstays of treatment for people with chronic obstructive pulmonary disease (COPD). Many patients use combinations of all three. Good evidence to support any combination is hard to come by, partly because patients find it hard to stick to their assigned treatment for long enough to show that it works. Still, researchers keep trying, and a team from Canada recently succeeded in reporting some clinically useful results.
In a trial of 449 adults with moderate to severe COPD, the combination of tiotropium, salmeterol, and fluticasone improved lung function and quality of life and reduced admission to hospital compared with tiotropium alone. It did not prevent exacerbations, one of the key aims of treatment. About 60% of patients in each group had an exacerbation requiring treatment with systemic steroids or antibiotics. In a third arm, adding salmeterol to tiopropium worked no better than tiopropium alone.
As expected, the dropout rate was high. More than 40% of patients treated with either tiotropium (74/156) or tiotropium plus salmeterol (64/148) failed to complete their treatment. Many started using inhaled steroids. This crossing over between groups means the negative results from this trial (on exacerbations) are less secure than the positive ones (on admission to hospital), say the authors.