Cost-effectiveness of salmeterol in patients with chronic obstructive pulmonary disease: an economic evaluation

Systematic review of models used in economic analyses in moderate-to-severe asthma and COPD

BACKGROUND

Respiratory diseases exert a substantial burden on society, with newer drugs increasingly adding to the burden. Economic models are often used, but seldom reviewed.

PURPOSE

To summarize economic models used in economic analyses of drugs treating moderate-to-severe/very severe asthma or chronic obstructive pulmonary disease (COPD).

METHODS

This study searched Medline and Embase from inception to the end of February 2015 for cost-effectiveness/utility analyses that examined at least one drug against placebo, another drug, or other standard therapy in asthma or COPD. Two reviewers independently searched and extracted data with differences adjudicated via consensus discussion. Data extracted included model used and its qualities, validation methods, treatments compared, disease severity, analytic perspective, time horizon, data collection (pro- or retrospective), input rates and sources, costs and sources, planned sensitivity analyses, criteria for cost-effectiveness, reported outcomes, and sponsor.

RESULTS

This study analyzed 53 articles; 14 (25%) on asthma and 39 (75%) COPD. Markov models were commonly used for both asthma and COPD-related economic evaluations. Relatively few studies validated their model. For asthma-related studies, 10 examined inhaled corticosteroids and nine studied omalizumab. Placebo or standard therapy was the comparison in 11 studies and active drugs in the remainder.

CONCLUSIONS

Few studies include validation of their models. Furthermore, controversy concerning some results was uncovered in this study, which needs to be avoided in the future.

Cost-effectiveness of pharmacotherapy for COPD in ambulatory care: a review

RATIONALE, AIMS AND OBJECTIVES

This article conducts a literature review about the cost-effectiveness of pharmacotherapy for chronic obstructive pulmonary disease (COPD) in ambulatory care.

METHODS

Relevant economic evaluations were identified by searching Medline (PubMed) and the National Health Service (NHS) Economic Evaluation Database. The search strategy focused on literature reviews and primary economic evaluations. Economic evaluations were included, which compared pharmacotherapy for COPD, chronic bronchitis or pulmonary emphysema with an alternative in terms of costs and health outcomes.

RESULTS

The majority of economic evaluations show that pharmacotherapy for COPD in ambulatory care is cost-effective. Cost-effectiveness derives from an improvement in lung function and a reduction in the number of exacerbations, which translates into cost savings from fewer hospitalizations. Pharmacotherapy also tends to be more cost-effective in patients with more severe COPD. When applying these results to a specific country or setting, the cost-effectiveness of pharmacotherapy will depend on the distribution of COPD severity among patients, the alternative with which pharmacotherapy is compared, the impact of pharmacotherapy on exacerbations, costs and treatment patterns of exacerbations, and price of pharmacotherapy. Economic evaluations tended to suffer from short-time horizons, restricted scope of included costs and use of various health outcome measures.

CONCLUSIONS

There is a case to be made in favour of economic evaluations from the societal perspective that are based on a decision-analytic model to allow for extrapolation beyond the duration of clinical trials and that use generic health outcome measures such as quality-adjusted life years.

Long-acting beta2-agonists for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a respiratory disease that causes progressive symptoms of breathlessness, cough and mucus build-up. It is the fourth or fifth most common cause of death worldwide and is associated with significant healthcare costs.Inhaled long-acting beta2-agonists (LABAs) are widely prescribed to manage the symptoms of COPD when short-acting agents alone are no longer sufficient. Twice-daily treatment with an inhaled LABA is aimed at relieving symptoms, improving exercise tolerance and quality of life, slowing decline and even improving lung function and preventing and treating exacerbations.

OBJECTIVES

To assess the effects of twice-daily long-acting beta2-agonists compared with placebo for patients with COPD on the basis of clinically important endpoints, primarily quality of life and COPD exacerbations.

SEARCH METHODS

We searched the Cochrane Airways Group trials register, ClinicalTrials.gov and manufacturers' websites in June 2013.

SELECTION CRITERIA

Parallel, randomised controlled trials (RCTs) recruiting populations of patients with chronic obstructive pulmonary disease. Studies were required to be at least 12 weeks in duration and designed to assess the safety and efficacy of a long-acting beta2-agonist against placebo.

DATA COLLECTION AND ANALYSIS

Data and characteristics were extracted independently by two review authors, and each study was assessed for potential sources of bias. Data for all outcomes were pooled and subgrouped by LABA agent (formoterol 12 μg, formoterol 24 μg and salmeterol 50 μg) and then were separately analysed by LABA agent and subgrouped by trial duration. Sensitivity analyses were conducted for the proportion of participants taking inhaled corticosteroids and for studies with high or uneven rates of attrition.

MAIN RESULTS

Twenty-six RCTs met the inclusion criteria, randomly assigning 14,939 people with COPD to receive twice-daily LABA or placebo. Study duration ranged from three months to three years; the median duration was six months. Participants were more often male with moderate to severe symptoms at randomisation; mean forced expiratory volume in 1 second (FEV1) was between 33% and 55% predicted normal in the studies, and mean St George's Respiratory Questionnaire score (SGRQ) ranged from 44 to 55 when reported.Moderate-quality evidence showed that LABA treatment improved quality of life on the SGRQ (mean difference (MD) -2.32, 95% confidence interval (CI) -3.09 to -1.54; I(2) = 50%; 17 trials including 11,397 people) and reduced the number of exacerbations requiring hospitalisation (odds ratio (OR) 0.73, 95% CI 0.56 to 0.95; I(2) = 10%; seven trials including 3804 people). In absolute terms, 18 fewer people per 1000 were hospitalised as the result of an exacerbation while receiving LABA therapy over a weighted mean of 7 months (95% CI 3 to 31 fewer). Scores were also improved on the Chronic Respiratory Disease Questionnaire (CRQ), and more people receiving LABA treatment showed clinically important improvement of at least four points on the SGRQ.The number of people who had exacerbations requiring a course of oral steroids or antibiotics was also lower among those taking LABA (52 fewer per 1000 treated over 8 months; 95% CI 24 to 78 fewer, moderate quality evidence).Mortality was low, and combined findings of all studies showed that LABA therapy did not significantly affect mortality (OR 0.90, 95% CI 0.75 to 1.08; I(2) = 21%; 23 trials including 14,079 people, moderate quality evidence). LABA therapy did not affect the rate of serious adverse events (OR 0.97, 95% CI 0.83 to 1.14; I(2) = 34%, moderate quality evidence), although there was significant unexplained heterogeneity, especially between the two formoterol doses.LABA therapy improved predose FEV1 by 73 mL more than placebo (95% CI 48 to 98; I(2) = 71%, low quality evidence), and people were more likely to withdraw from placebo than from LABA therapy (OR 0.74, 95% CI 0.69 to 0.80; I(2) = 0%). Higher rates of withdrawal in the placebo arm may reduce our confidence in some results, but the disparity is more likely to reduce the magnitude of difference between LABA and placebo than inflate the true effect; removing studies at highest risk of bias on the basis of high and unbalanced attrition did not change conclusions for the primary outcomes.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from 26 studies showed that inhaled long-acting beta2-agonists are effective over the medium and long term for patients with moderate to severe COPD. Their use is associated with improved quality of life and reduced exacerbations, including those requiring hospitalisation. Overall, findings showed that inhaled LABAs did not significantly reduce mortality or serious adverse events.

Risk of all-cause hospitalization in COPD patients initiating long-acting or short-acting beta agonist therapy

OBJECTIVE

This retrospective claims study investigated the rates of all-cause hospitalization among chronic obstructive pulmonary disease (COPD) patients initiating treatment with short-acting beta agonists (SABA) or long-acting beta agonists (LABA).

METHODS

Data from the 5% national sample of Medicare enrollees for 2006-2008 were used. Patients initiating COPD therapy were identified as those with no COPD therapy for ≥ 6-months prior to initiating SABA or LABA (administered via dry-powder inhalers, metered-dose inhalers, or nebulizer) treatment. All patients were continuously eligible for Medicare Parts A, B, and D for 18 months. Those enrolled in Medicare Advantage, who had asthma, or were < 65 years old were excluded. Differences in the rates of all-cause hospitalizations and time to all-cause hospitalization during the 6-month follow-up period were examined, while adjusting for demographics, clinical indicators, and health service use.

RESULTS

Among 3017 COPD patients who met the inclusion criteria, 883 (30%) were LABA users and 2134 (70%) were SABA users. Overall, 21% of patients (16% [144/883] of LABA and 23% [492/2134] of SABA) had a hospitalization during the follow-up period. Mean time to hospitalization was 86 days for LABA vs 64 days for SABA patients (p < 0.05). The adjusted hazard ratio for hospitalization in a Cox proportional hazards model was 0.74 (95% CI = 0.62-0.90) for patients treated with LABA vs. SABA.

LIMITATIONS

The analysis was adjusted for multiple background characteristics, but important measures of severity in COPD, such as measures of lung functioning, were not available and may have differed between patients treated with LABA or SABA.

CONCLUSIONS

The results of this analysis indicate COPD patients initiating LABA treatment had a longer time to all-cause hospitalization and a 26% lower risk of hospitalization during the 6-months follow-up period compared to those initiating SABA therapy.

Cost effectiveness of pharmacological maintenance treatment for chronic obstructive pulmonary disease: a review of the evidence and methodological issues

BACKGROUND

Over 200 million people have chronic obstructive pulmonary disease (COPD) worldwide. The number of disease-year equivalents and deaths attributable to COPD are high. Guidelines for the pharmacological treatment of the disease recommend an individualized step-up approach in which treatment is intensified when results are unsatisfactory.

OBJECTIVE

Our objective was to present a systematic review of the cost effectiveness of pharmacological maintenance treatment for COPD and to discuss the methodological strengths and weaknesses of the studies.

METHODS

A systematic literature search for economic evaluations of drug therapy in COPD was performed in MEDLINE, EMBASE, the Economic Evaluation Database of the UK NHS (NHS-EED) and the European Network of Health Economic Evaluation Databases (EURONHEED). Full economic evaluations presenting both costs and health outcomes were included.

RESULTS

A total of 40 studies were included in the review. Of these, 16 were linked to a clinical trial, 14 used Markov models, eight were based on observational data and two used a different approach. The few studies on combining short-acting bronchodilators were consistent in finding net cost savings compared with monotherapy. Studies comparing inhaled corticosteroids (ICS) with placebo or no maintenance treatment reported inconsistent results. Studies comparing fluticasone with salmeterol consistently found salmeterol to be more cost effective. The cost-effectiveness studies of tiotropium versus placebo, ipratropium or salmeterol pointed towards a reduction in total COPD-related healthcare costs for tiotropium in many but not all studies. All of these studies reported additional health benefits of tiotropium. The cost-effectiveness studies of the combination of inhaled long-acting β₂-agonists and ICS all report additional health benefits at an increase in total COPD-related costs in most studies. The cost-per-QALY estimates of this combination treatment vary widely and are very sensitive to the assumptions on mortality benefit and time horizon.

CONCLUSIONS

The currently available economic evaluations indicate differences in cost effectiveness between COPD maintenance therapies, but for a more meaningful comparison of results it is important to improve the consistency with respect to study methodology and choice of comparator.

[Individually-tailored treatment of chronic obstructive pulmonary disease: a proposed change]

Chronic obstructive pulmonary disease (COPD) is a highly prevalent but poorly defined disease and there is wide confusion regarding its treatment. The available knowledge should allow guidelines for specific treatment to be established according to each patient's clinical features. The present article describes a proposal for individually-tailored treatment. Long-acting bronchodilators, alone or in various combinations, would be the basis of treatment and inhaled corticosteroids (IC) should be used in a subgroup with well-defined characteristics. The latest studies indicate that the benefits of IC are limited in COPD and that the risks are not inconsiderable. Consequently, these drugs should be limited to "responders" and should always be administered in association with a long-acting beta(2) bronchodilator. The pathogenesis of this disease should be studied in greater depth and patients should be classified according to their severity, the frequency of acute exacerbations, their reversibility, comorbidity and concomitant medication in order to choose the most appropriate treatment.

A new method for examining the cost savings of reducing COPD exacerbations

BACKGROUND

Some treatments for chronic obstructive pulmonary disease (COPD) can reduce exacerbations, and thus could have a favourable impact on overall healthcare costs.

OBJECTIVE

To evaluate a new method for assessing the potential cost savings of COPD controller medications based on the incidence of exacerbations and their related resource utilization in the general population.

METHODS

Patients with COPD (n = 1074) enrolled in a regional managed care system in the US were identified using administrative data and divided by their medication use into three groups (salbutamol, ipratropium and salmeterol). Exacerbations were captured using International Classification of Diseases, Ninth Edition (ICD-9) and current procedural terminology (CPT) codes, then logistic regression models were created that described the risk of exacerbations for each comparator group and exacerbation type over a 6-month period. A Monte Carlo simulation was then applied 1000 times to provide the range of potential exacerbation reductions and cost consequences in response to a range of hypothetical examples of COPD controller medications.

RESULTS

Exacerbation events for each group could be modelled such that the events predicted by the Monte Carlo estimates were very close to the actual prevalences. The estimated cost per exacerbation avoided depended on the incidence of exacerbation in the various subpopulations, the assumed relative risk reduction, the projected daily cost for new therapy, and the costs of exacerbation treatment.

CONCLUSIONS

COPD exacerbation events can be accurately modelled from the healthcare utilization data of a defined cohort with sufficient accuracy for cost-effectiveness analysis. Treatments that reduce the risk or severity of exacerbations are likely to be cost effective among those patients who have frequent exacerbations and hospitalizations.

Modelling the 5-year cost effectiveness of tiotropium, salmeterol and ipratropium for the treatment of chronic obstructive pulmonary disease in Spain

Our objective was to assess the 5-year cost effectiveness of bronchodilator therapy with tiotropium, salmeterol or ipratropium for chronic obstructive pulmonary disease (COPD) from the perspective of the Spanish National Health System (NHS). A probabilistic Markov model was designed wherein patients moved between moderate, severe or very severe COPD and had the risk of exacerbation and death. Probabilities were derived from clinical trials. Spanish healthcare utilisation, costs and utilities were estimated for each COPD and exacerbation state. Outcomes were exacerbations, exacerbation-free months, quality-adjusted life years (QALYs), and cost(-effectiveness). The mean (SE) 5-year number of exacerbations was 3.50 (0.14) for tiotropium, 4.16 (0.40) for salmeterol and 4.71 (0.54) for ipratropium. The mean (SE) number of QALYs was 3.15 (0.08), 3.02 (0.15) and 3.00 (0.20), respectively. Mean (SE) 5-year costs were 6,424 euro (305 euro) for tiotropium, 5,869 euro (505 euro) for salmeterol, and 5,181 euro (682 euro) for ipratropium (2005 values). Ipratropium and tiotropium formed the cost-effectiveness frontier, with tiotropium being preferred when willingness to pay (WTP) exceeded 639 euro per exacerbation-free month and 8,157 euro per QALY. In Spain, tiotropium demonstrated the highest expected net benefit for ratios of the willingness to pay per QALY, well within accepted limits.

One hundred years of chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.

An appraisal of pharmacoeconomic evidence of maintenance therapy for COPD

COPD is projected to be the third-leading cause of death by the year 2020. Pharmacotherapy for COPD is palliative at best, having no impact on slowing the progression of the disease. The introduction of newer therapies such as long-acting forms of bronchodilator and anticholinergic agents, together with the inclusion of inhaled corticosteroids (ICSs) in the recent Global Initiative for COPD therapeutic algorithm, have expanded the pharmacotherapy options for the treatment of COPD. This article provides a methodologic critique of the available pharmacoeconomic evidence on drug therapy for stable COPD in an effort to complement treatment guidelines and to identify any need for future pharmacoeconomic research. Relevant search strategies revealed a total of 28 economic evaluations of which 7 satisfied the study inclusion criteria. The Drummond 10-point checklist was used for the methodological critique of the economic evaluations. Five of seven pharmacoeconomic studies were conducted alongside a randomized controlled trial, and six of seven were cost-effectiveness analyses. Of the bronchodilators, the long-acting anticholinergic agent tiotropium is considered to be cost-effective relative to ipratropium. No conclusive information could be reached for the cost-effectiveness of long-acting beta-agonists. A Markov analysis showed ICSs to be cost-effective for patients with moderate-to-severe COPD relative to standard care. However, assumptions of the model may bias this conclusion, and additional studies are warranted, especially compared to other treatments. The authors suggest that additional pharmacoeconomic studies be conducted to assess the cost-effectiveness of long-acting beta-agonists and ICSs, between classes of bronchodilators, and between various combination therapies.

Economic evaluation of treating chronic obstructive pulmonary disease with inhaled corticosteroids and long-acting beta2-agonists in a health maintenance organization

OBJECTIVES

In light of recent results from observational studies showing prolonged survival in subjects taking long-acting beta2-agonists (LABA) and/or inhaled corticosteroids (ICS) for chronic obstructive pulmonary disease (COPD), we investigated their cost-effectiveness (CE).

METHODS

Costs and survival data were collected for a sample of members enrolled in a large Health Maintenance Organization in the United States. An observational study design was used to evaluate cumulative costs and health benefits of LABA, ICS, ICS+LABA, or comparison drugs. Survival was estimated using a parametric regression model. Costs were adjusted for censoring and prognostic factors. CE was evaluated over a time horizon of 36 months and the remaining lifetime of subjects.

RESULTS

Over 36 months, life expectancy and costs were: 2.4 years (95% confidence interval (CI): 2.3; 2.5) and $28,030 (CI: $23,400; $33,570) for not receiving ICS or LABA; 2.6 years (CI: 2.6; 2.7) and $35,170 (CI: $29,970; $40,620) for ICS alone; 2.6 years (CI: 2.5; 2.7) and $27,380 (CI: $21,780; $32,510) for LABA alone; and, 2.7 years (CI: 2.6; 2.8) and $33,780 (CI: $28,700; $39,440) for subjects treated with ICS+LABA. The lifetime analysis showed similar trends.

CONCLUSIONS

There is an acute need to find effective, life-extending treatments for persons with COPD. ICS, LABA or their combination represent promising treatment options and are currently being tested in randomized trials. If the impact on survival seen in these trials compares to that seen in observational studies, LABA and the combination treatment are likely to be cost-effective in the United States.

Epidemiology and health economics of COPD across Europe: a critical analysis

COPD is a major cause of morbidity and mortality in Europe. The purpose of this literature review was to critically evaluate published data on COPD prevalence and the cost of COPD interventions in European countries. Selection of literature was based on article retrieval from a systematic literature search using PubMed and EMBASE. Only articles providing data in European countries published between January 1990 and March 2003 were included. European epidemiological (cross-sectional, cohort, case-control) and economic (cost-of-illness-, cost-minimization-, cost-effectiveness-, cost-benefit-, cost-utility-analysis) studies were included. Of 74 retrieved epidemiologic studies, only seven (9%) fulfilled the inclusion criteria. In the selected literature, COPD prevalence ranged from 3% among Finnish women to 57% among Italian men and women, 45 years and older. Of 56 economic studies, 24 satisfied entry criteria. Results from the final cost-of-illness studies indicated that hospital care and medication represented the major portion of costs associated with COPD. In a survey conducted in 1998/99, annual direct expenditures for COPD treatment per patient in Europe ranged from Euro 530 in France to Euro 3238 in Spain. There was a differential increase in COPD prevalence predominantly related to an aging patient population, with a high incidence of exposure to cigarette smoke. Data also showed differences in the economic impact of COPD in Europe based on the proportion of patients with severe COPD, frequency of exacerbations, and number of hospitalizations. Overall, results of this review demonstrated the need for global epidemiologic and economic studies to allow for more uniform guidelines for the prevention and cost-effective treatment of patients with COPD.

Is a long-acting inhaled bronchodilator the first agent to use in stable chronic obstructive pulmonary disease?

PURPOSE OF REVIEW

This article reviews findings from recently published randomized controlled clinical trials to address the question whether a long-acting inhaled bronchodilator should be the initial choice for maintenance therapy in patients with stable, symptomatic chronic obstructive pulmonary disease (COPD).

RECENT FINDINGS

Results of recent clinical trials suggest that a long-acting inhaled bronchodilator, either once-daily tiotropium or twice-daily salmeterol or formoterol, has advantages over a regularly-scheduled short-acting anticholinergic inhaled bronchodilator (ipratropium) as initial maintenance therapy in patients with at least moderate, stable, symptomatic COPD (forced expired volume in 1 second </= 60-70% predicted; mean, approximately 37-45% predicted). For tiotropium, these advantages encompass several important outcomes, including lung function, rescue inhaler use, dyspnea, frequency of exacerbations, and hospitalization for COPD, in addition to greater convenience and therefore potentially better adherence to prescribed therapy, whereas side effects are similar except for a greater incidence of dry mouth.

SUMMARY

Current evidence supports the recommendation of the Global Initiative for Chronic Obstructive Lung Disease guidelines of at least one of the two classes of long-acting inhaled bronchodilators as initial maintenance therapy for symptomatic COPD. In patients who do not respond satisfactorily to tiotropium or a long-acting inhaled beta-agonist as the initially prescribed single maintenance agent, the Global Initiative for Chronic Obstructive Lung Disease guidelines recommend the addition of the alternate class of long-acting inhaled bronchodilator as the next step. Further clinical trials are required to investigate whether this recommendation is preferable to that of adding an inhaled corticosteroid, which has been shown to have additive benefits to those of a long-acting beta-agonist with respect to bronchodilation and, variably, dyspnea, rescue bronchodilator use, and quality of life. The choice of agents will depend ultimately on how well the patient responds to a trial of the drug in terms of both efficacy and side effects, and patient preference and cost.

Enfermedad pulmonar obstructiva crónica

Treatment of chronic obstructive pulmonary disease (COPD) has underwent a very important advance in the last five years. It has been developed a new long-lasting anticholynergic drug, tiotrope bromure, which has been found to improve lung function and exercise capacity and to decrease relapses. Also the combined treatment of long lasting beta 2 adrenergics with inhaled steroids (salmeterol/fluticasone and formoterol/budesonide) has proven similar results. However, the response to these new drugs is not the same in all patients. Individual characteristics such as gravity, degree of bronchial hyperresponsiveness, frequency of relapses, comorbidity, etc will determine the response to several agents. Thus, it is necessary to perform a detailed diagnostic study in COPD patients in order to select the best treatment in an individualized form. In the future, new specific antiinflammatories such as phosphodiesterase 4 inhibitors or agents with a potential action in tissue regeneration could lead to new perspectives, as well as to new questions, in COPD treatment.

Assessment of progression of COPD: report of a workshop held in Leuven, 11-12 March 2004

Recently performed long term trials have enhanced the insight into the assessment of progression of COPD. The present review focuses on the initial assessment of COPD in general practice and the assessment of disease progression. Several variables may be used to assess this progression, all of which are associated with significant methodological problems. Finding the appropriate mix of outcome measures to capture all aspects of disease progression is a significant challenge.

Chronic obstructive pulmonary disease: is there a case for early intervention?

Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition that represents a significant economic burden to society. Early diagnosis of COPD offers the best opportunity to slow the progression of the disease through smoking cessation. Aggressive medical management of COPD for patients diagnosed at a moderate or severe stage is likely to be attractive from an economic standpoint, although prospective studies are needed to validate current evidence. Poor adherence to smoking cessation and pharmacologic therapy suggests that patient education is critical to successful intervention at all stages of illness. The economic value of aggressive pharmacotherapy for early-stage COPD is less certain, but the burden of illness and potential pharmacoeconomic benefits in such patients is a strong rationale for combined clinical and economic trials.

Inhaled Combination Therapy With Long-Acting β 2 -Agonists and Corticosteroids in Stable COPD

Long-acting beta(2)-agonists (LABAs) have been shown to be effective first-line bronchodilators in the treatment of COPD patients, and inhaled corticosteroids (ICSs) have been shown to reduce the frequency and/or severity of exacerbations in COPD patients. The concomitant use of a LABA and an ICS can influence both airway obstruction (ie, smooth muscle contraction, increased cholinergic tone, and loss of elastic recoil), and airway inflammation (ie, increased numbers of neutrophils, macrophages, and CD8+ lymphocytes, elevated interleukin-8 and tumor necrosis factor-alpha levels, and protease/antiprotease imbalance). They are also able to reduce the total number of bacteria adhering to the respiratory mucosa in a concentration-dependent manner without altering the bacterial tropism for mucosa, and to preserve ciliated cells. Several clinical trials support the concept of inhaled combination therapy with LABAs and corticosteroids in stable COPD patients. This type of therapy not only improves airflow obstruction but also provides clinical benefits, as manifested by sustained reduction in overall symptoms, improvements in health-related quality of life, and reductions in exacerbations. All of these effects are very important because, despite recent advances in our understanding of COPD and its treatment, therapy remains suboptimal for a considerable number of patients.