Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease

Nanotechnology based advanced therapeutic strategies for targeting interleukins in chronic respiratory diseases

Both communicable and non-communicable chronic respiratory conditions have accorded for suffering of millions of people of all ages and stated to be leading cause of death, morbidity, economic and social pressures, and disability-adjusted life-years (DALYs) worldwide. These illnesses impair patient's health and negatively impacts families and society, particularly in low and middle-income countries. Chronic respiratory diseases (CRDs) affect different organs of respiratory system, involving airways, parenchyma, and pulmonary vasculature. As the number of respiratory diseases are exponentially escalating but still the stakeholders are not paying attention towards its serious complications. Currently, the treatment being used primarily focusses only on alleviating symptoms of these illness rather delivering the therapeutic agent at target site for optimal care and/or prevention. Lately, extensive research is being conducted on airways and systemic inflammation, oxidative stress, airway, or parenchymal rehabilitation. From which macrophages, neutrophils, and T cells, as well as structural cells as fibroblasts, epithelial, endothelial, and smooth muscle cells have been found to be active participants that are involved in these chronic respiratory diseases. The pathogenesis of all these chronic respiratory diseases gets caused differently via mediators and proteins, including cytokines, chemokines, growth factors and oxidants. Presently, the target of prescription therapies is to reduce the inflammation of airways and relieve the airway contraction. In all studies, cytokines have been found to play an imperative role in fostering chronic airway inflammation and remodelling. Owing to the limitations of conventional treatments, the current review aims to summarize the current knowledge about the chronic respiratory disease and discuss further about the various conventional methods that can be used for treating this ailment. Additionally, it also highlights and discusses about the advanced drug delivery system that are being used for targeting the interleukins for the treatment of CRDs.

Inhaled corticosteroids and the increased risk of pulmonary tuberculosis: a population-based case-control study

AIMS

The association between inhaled corticosteroid (ICS) use and pulmonary tuberculosis (TB) development is uncertain. We conducted a population-based case-control study to investigate whether ICS use increases the risk of developing TB.

METHODS

Tuberculosis patients aged 18 years and older were identified using the National Health Insurance Research Database (NHIRD) in Taiwan between 2002 and 2010. Each TB patient was frequency matched to four control patients according to age, sex and index year. We retrospectively followed up the medications and comorbid medical conditions for the 5 years prior to the index date. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) of TB development using multiple logistic regression models.

RESULTS

Most of the study participants were men (68.7%), and the mean age among the 8091 TB patients and 32,364 comparison participants was 61.3 ± 18.6 years. After adjusting for potential covariates, ICS use caused a 2.04-fold increased risk of developing TB (adjusted OR: 2.04, 95% CI: 1.78-2.33). When considering dose-response and adjusting for potential covariates, ICS and oral corticosteroids (OCS) use remained independent risk factors and exhibited a dose-response relationship of TB development. The multiplicative increased risk of TB was also significant in patients using ICS and OCS compared with patients not using ICS and OCS (adjusted OR: 4.31, 95% CI: 3.39-5.49). Previous TB history exhibited the greatest risk of TB development among the comorbidities (adjusted OR: 8.50, 95% CI: 7.52-9.61).

CONCLUSION

Long-term ICS use may increase the risk of TB.

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

OBJECTIVES

To determine the efficacy and safety of inhaled corticosteroids in stable patients with COPD, in terms of objective and subjective outcomes.

SEARCH METHODS

A pre-defined search strategy was used to search the Cochrane Airways Group Specialised Register for relevant literature. Searches are current as of July 2011.

SELECTION CRITERIA

We included randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta(2)-agonists and bronchial hyper-responsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. We also analysed data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Fifty-five primary studies with 16,154 participants met the inclusion criteria. Long-term use of ICS (more than six months) did not consistently reduce the rate of decline in forced expiratory volume in one second (FEV(1)) in COPD patients (generic inverse variance analysis: mean difference (MD) 5.80 mL/year with ICS over placebo, 95% confidence interval (CI) -0.28 to 11.88, 2333 participants; pooled means analysis: 6.88 mL/year, 95% CI 1.80 to 11.96, 4823 participants), although one major trial demonstrated a statistically significant difference. There was no statistically significant effect on mortality in COPD patients (odds ratio (OR) 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long-term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: MD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants; pooled means analysis: MD -0.19 exacerbations per patient per year, 95% CI -0.30 to -0.08, 2253 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.65, 95% CI 2.03 to 3.46, 5586 participants) and hoarseness. In the long-term studies, the rate of pneumonia was increased in the ICS group compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.56, 95% CI 1.30 to 1.86, 6235 participants). The long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years.

AUTHORS' CONCLUSIONS

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life and possibly reduced rate of decline in FEV(1)) against the potential side effects (oropharyngeal candidiasis and hoarseness, and risk of pneumonia).

The effect of inhaled salmeterol, alone and in combination with fluticasone propionate, on management of COPD patients

INTRODUCTION

  Airway inflammation is a known pathological feature of chronic obstructive pulmonary disease (COPD). We examined the effect of inhaled salmeterol, alone and in combination with fluticasone propionate, on the management of patients with COPD.

METHODS

  Forty male COPD patients were randomly divided into two groups; group 1 (n=20) were treated with long-acting ß2-agonist, and group 2 (n=20) with long-acting ß2-agonist and inhaled glucocoticoid each day for 3 months. Pulmonary function tests (PFTs), including forced vital capacity (FVC), forced expiratory volume in 1s (FEV1) and peak expiratory flow (PEF), were measured at the beginning, 1 and 2 months after treatment and at the end of the study. The frequency of using inhaled salbutamol/day and the 6-min walk distance were also measured at four different visits. The frequency of exacerbation was also recorded during the 90-day treatment period in the two groups.

RESULTS

  FEV(1) , FVC and PEF were significantly higher after 30 days of treatment with fluticasone propionate (mean change from baseline in group 2: 155mL, 200mL and 70L/s, respectively; P<0.001). Six-minute walk distance also increased significantly (mean change from baseline: 160 m; P < 0.001), and there was a 70%-80% reduction in the use of inhaled salbutamol (P<0.001). All improvements were maintained over the remainder of the study period. Exacerbations over the 90-day treatment period were significantly fewer than in the same 90-day period in the previous year (2.8±0.7 vs 0.8±0.9; P<0.001). In contrast, only PEF increased significantly with treatment in group 1 (salmeterol treatment alone).

CONCLUSIONS

  These results indicated that inhaled corticosteroids may be beneficial in some patients with COPD.

The impact of inhaled corticosteroid and long-acting beta-agonist combination therapy on outcomes in COPD

Chronic obstructive pulmonary disease (COPD) is an under-recognized cause of morbidity and mortality worldwide that imposes an ever increasing burden on the patient and society alike. The disease encompasses multiple structural and functional components of which inflammation is at the core of the disease, affecting the lungs and other organs. Consequently, current treatment strategies are aimed at treating both the symptoms and the pulmonary inflammation underlying the complex pathophysiology of COPD. Smoking cessation is the only intervention currently shown to slow disease progression in COPD and decrease all-cause mortality, aside from lung transplant, lung-volume reduction surgery and oxygen therapy in selective patients. However, this intervention is difficult to achieve and sustain because of the addictive and chronic relapsing nature of cigarette smoking. Pharmacotherapy with bronchodilating agents, including the beta 2-agonists, anticholinergics and methylxanthines, is central to the symptomatic management of all stages of COPD. While inhaled corticosteroids (ICS) are employed to reduce inflammation in more severe patients, their role as stand alone medication in COPD is not well defined. However, increasing evidence suggests that long-acting beta 2-agonists (LABAs) and ICS have complementary and synergistic effects, when delivered as combination therapy from a single inhaler. In this respect, two preparations comprising combinations of salmeterol+fluticasone propionate (SFC) and formoterol+budesonide (FBC) are currently available and employed for treatment of more severe disease. Several large-scale studies in patients with moderate-to-severe COPD have demonstrated that treatment with SFC and FBC leads to significantly greater improvements in lung function, exacerbations, health status and breathlessness, compared with placebo or monotherapy with the component drugs. In the recently published landmark study, Towards a Revolution in COPD Health (TORCH), regular treatment with SFC narrowly missed demonstrating a statistically significant benefit on the reduction in all-cause mortality over 3 years (17.5% reduction in risk, P=0.052), further emphasizing the clinical usefulness of LABA+ICS therapy in COPD. In view of this increasing evidence for the additional effectiveness of LABA+ICS combinations compared with the individual components, and the potential benefits of LABA+ICS on lung function, disease progression and potentially on all-cause mortality, initiation of LABA+ICS combination treatment early in the COPD disease process may be warranted.

SEARCH STRATEGY

The studies discussed in this review were identified from systematic searches of Medline and the Cochrane Database, up to October 2007, for articles in English or with English abstracts describing randomized, double-blind, parallel-group/crossover trials of at least 24 weeks' duration. All searches were performed using the terms: chronic obstructive pulmonary disease, COPD, chronic obstructive airway disease, or COAD AND either salmeterol, formoterol, long-acting beta 2-adrenoceptor agonist, fluticasone propionate, budesonide, inhaled corticosteroids, or inhaled glucocorticosteroids. Additional relevant references were identified from the reference lists of selected papers. Only studies that compared a combined LABA+ICS therapy with its monotherapy components were selected for inclusion in this manuscript.

A modified prescription-event monitoring study to assess the introduction of Flixotide Evohaler into general practice in England: an example of pharmacovigilance planning and risk monitoring

INTRODUCTION

A modified prescription-event monitoring (PEM) study was conducted to examine the safety of the introduction of the metered dose inhaler (MDI) Flixotide Evohaler (fluticasone with the propellant HFA 134a).

METHODS

Patients were identified from the first NHS prescriptions dispensed in England for Flixotide Evohaler. Postal questionnaires were sent to the prescribing doctor, requesting information including: demographic characteristics, severity of indication, concomitant medication, event data 3 months prior to and 3 months after the first prescription, and any reasons for stopping Flixotide. Pregnancies, deaths and selected events were followed up. Incidence density ratios (IDRs) were calculated to compare event rates 3 months before and 3 months after the introduction of Flixotide Evohaler.

RESULTS

The cohort comprised 13 413 patients that were prescribed Flixotide Evohaler. The response rate was 64.0%. When the pre- and post-exposure periods were compared fewer patients had events in the post-exposure period, and there was no significant difference in the length of courses of oral steroid use. Eighteen patients experienced an event within 1 hour of using Flixotide Evohaler; these were minor with the exception of one case of angioneurotic facial oedema. Six of these events were assessed as possibly related to Flixotide Evohaler. During the study period there were an additional 13 patients with events assessed as possibly related to Flixotide Evohaler, including two reports of allergic reactions.

DISCUSSION

The results suggest that the transition to Flixotide Evohaler was generally well tolerated. The modified methodology has contributed to the risk management of the introduction of this product.

The oral, once-daily phosphodiesterase 4 inhibitor roflumilast lacks relevant pharmacokinetic interactions with inhaled budesonide

This open-label, randomized, 3-period crossover study evaluated the pharmacokinetic interaction potential of roflumilast and budesonide following repeated coadministration to healthy male subjects (N = 12). Treatments consisted of oral roflumilast 500 mug, once daily, orally inhaled budesonide 800 mug, twice daily, and concomitant administration of both treatments for 7 days each. Roflumilast and roflumilast N-oxide in plasma and budesonide serum levels were measured by specific assays. Geometric mean test/reference ratios of steady-state pharmacokinetic parameters were evaluated by analysis of variance. Safety and tolerability were monitored. Pharmacokinetic parameters of roflumilast, roflumilast N-oxide, and budesonide after coadministration of roflumilast and budesonide were similar to those after mono-treatment. Compared with budesonide and roflumilast mono-treatments, slightly lower maximum serum/plasma concentration (C(max)) and area under the curve (AUC) values of roflumilast N-oxide and budesonide (ranging from -8% to -16%) were observed with combined treatment. All test/reference ratios were within predefined equivalence acceptance ranges for roflumilast AUC (0.80, 1.25) and C(max) (0.70, 1.43) and for roflumilast N-oxide and budesonide AUC and C(max) (all 0.67, 1.50). Coadministration of roflumilast and budesonide did not alter the steady-state disposition of each other and did not affect safety and tolerability of either drug.

Airways disease: phenotyping heterogeneity using measures of airway inflammation

: Despite asthma and chronic obstructive pulmonary disease being widely regarded as heterogeneous diseases, a consensus for an accurate system of classification has not been agreed. Recent studies have suggested that the recognition of subphenotypes of airway disease based on the pattern of airway inflammation may be particularly useful in increasing our understanding of the disease. The use of non-invasive markers of airway inflammation has suggested the presence of four distinct phenotypes: eosinophilic, neutrophilic, mixed inflammatory and paucigranulocytic asthma. Recent studies suggest that these subgroups may differ in their etiology, immunopathology and response to treatment. Importantly, novel treatment approaches targeted at specific patterns of airway inflammation are emerging, making an appreciation of subphenotypes particularly relevant. New developments in phenotyping inflammation and other facets of airway disease mean that we are entering an era where careful phenotyping will lead to targeted therapy.

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

OBJECTIVES

The objective of the review is to determine the efficacy of regular use of inhaled corticosteroids in patients with stable COPD.

SEARCH STRATEGY

A pre-defined search strategy was used to search the Cochrane Airways Group specialised register for relevant literature. Searches are current as of October 2006.

SELECTION CRITERIA

We selected randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short term beta2-agonists and bronchial hyperresponsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. Data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety were also analysed.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Forty-seven primary studies with 13,139 participants met the inclusion criteria. Medium term use of ICS (> two months and up to six months) resulted in a small improvement in FEV1 in some studies. Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients (weighted mean difference (WMD) 5.80 ml/year with ICS over placebo, 95% CI -0.28 to 11.88, 2333 participants). There was no statistically significant effect on mortality in COPD patients (OR 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (WMD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (WMD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.49, 95% CI 1.78 to 3.49, 4380 participants) and hoarseness. The few long term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over 3 years.

AUTHORS' CONCLUSIONS

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life), against the known increase in local side effects (oropharyngeal candidiasis and hoarseness). The risk of long term adverse effects is unknown.

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.

Persistent effects induced by IL-13 in the lung

IL-13 overexpression in the lung induces inflammatory and remodeling responses that are prominent features of asthma. Whereas most studies have concentrated on the development of IL-13-induced disease, far fewer studies have focused on the reversibility of IL-13-induced pathologies. This is particularly important because current asthma therapy appears to be poor at reversing lung remodeling. In this manuscript, we used an externally regulatable transgenic system that targets expression of IL-13 to the lung with the aim of characterizing the reversibility process. After 4 wk of doxycycline (dox) exposure, IL-13 expression resulted in mixed inflammatory cell infiltration, mucus cell metaplasia, lung fibrosis, and airspace enlargement (emphysema). After withdrawal of dox, IL-13 protein levels were profoundly reduced by 7 d and below baseline by 14 d. During this time frame, the level of lung eosinophils returned to near normal, whereas macrophages, lymphocytes, and neutrophils remained markedly elevated. IL-13-induced mucus cell metaplasia significantly decreased (91%) 3 wk after withdrawal of dox, showing strong correlation with reduced eosinophil levels. In contrast, IL-13-induced lung fibrosis did not significantly decline 4 wk after dox withdrawal. Importantly, IL-13-induced emphysema persisted, but modestly declined 4 wk after dox. Examination of transcript expression profiles identified a subset of genes that remained increased weeks after transgene expression was no longer detected. Notably, numerous IL-13-induced cytokines and enzymes were reversible (IL-6 and cathepsins), whereas others were sustained (CCL6 and chitinases) after IL-13 withdrawal, respectively. Thus, several hallmark features of IL-13-induced lung pathology persist and are dissociated from eosinophilia after IL-13 overexpression ceases.

Beta-adrenoceptor responses of the airways: for better or worse?

Beta2-adrenoceptor agonists are the first-line treatment of asthma and chronic obstructive pulmonary disease (COPD), in which a short-acting beta2-adrenoceptor agonist is used as required for relief of bronchoconstriction. A long-acting beta2-adrenoceptor agonist may be added to an inhaled corticosteroid as step 3 in the management of chronic asthma. Long-acting beta2-adrenoceptor agonists may also be added in treatment of COPD. This review examines the beneficial and detrimental effects of beta2-adrenoceptor agonists. The beneficial effects of beta2-adrenoceptor agonists are mainly derived from their bronchodilator activity which relieves the bronchiolar narrowing and improves air flow. The potential anti-inflammatory actions of stabilizing mast cell degranulation and release of inflammatory and bronchoconstrictor mediators, is considered. Other potential beneficial responses include improvements in mucociliary clearance and inhibition of extravasation of plasma proteins that is involved in oedema formation in asthma. The side effects of beta2-adrenoceptor agonists are primarily related to beta2-adrenoceptor-mediated responses at sites outside the airways. Of major concern has been the development of tolerance and this is discussed in relation to incidence of increased morbidity and mortality to asthma over the past three decades. A clinical aspect of beta2-adrenoceptor pharmacology in recent years has been the recognition of genetic polymorphism of the receptor and how this affects responses to and tolerance to beta2-adrenoceptor agonists. A controversial feature of beta2-adrenoceptor agonists is their stereoisomerism and whether the inactive (S)-isomer of salbutamol had detrimental actions in the commercially used racemate. The consensus is that despite these adverse properties, beta2-adrenoceptor agonist remains the most useful pharmacological agents in the management of asthma and COPD.

Can inhaled fluticasone alone or in combination with salmeterol reduce systemic inflammation in chronic obstructive pulmonary disease? Study protocol for a randomized controlled trial [NCT00120978]

Background

Systemic inflammation is associated with various complications in chronic obstructive pulmonary disease including weight loss, cachexia, osteoporosis, cancer and cardiovascular diseases. Inhaled corticosteroids attenuate airway inflammation, reduce exacerbations, and improve mortality in chronic obstructive pulmonary disease. Whether inhaled corticosteroids by themselves or in combination with a long-acting β₂-adrenoceptor agonist repress systemic inflammation in chronic obstructive pulmonary disease is unknown. The Advair Biomarkers in COPD (ABC) study will determine whether the effects of inhaled corticosteroids alone or in combination with a long-acting β₂-adrenoceptor agonist reduce systemic inflammation and improve health status in patients with chronic obstructive pulmonary disease.

Methods/Design

After a 4-week run-in phase during which patients with stable chronic obstructive pulmonary disease will receive inhaled fluticasone (500 micrograms twice daily), followed by a 4-week withdrawal phase during which all inhaled corticosteroids and long acting β₂-adrenoceptor agonists will be discontinued, patients will be randomized to receive fluticasone (500 micrograms twice daily), fluticasone/salmeterol combination (500/50 micrograms twice daily), or placebo for four weeks. The study will recruit 250 patients across 11 centers in western Canada. Patients must be 40 years of age or older with at least 10 pack-year smoking history and have chronic obstructive pulmonary disease defined as forced expiratory volume in one second to vital capacity ratio of 0.70 or less and forced expiratory volume in one second that is 80% of predicted or less. Patients will be excluded if they have any known chronic systemic infections, inflammatory conditions, history of previous solid organ transplantation, myocardial infarction, or cerebrovascular accident within the past 3 months prior to study enrolment. The primary end-point is serum C-reactive protein level. Secondary end-points include circulating inflammatory cytokines such as interleukin-6 and interleukin-8 as well as health-related quality of life and lung function.

Discussion

If inhaled corticosteroids by themselves or in combination with a long-acting β₂-adrenoceptor agonist could repress systemic inflammation, they might greatly improve clinical prognosis by reducing various complications in chronic obstructive pulmonary disease.

The role of combination therapy with corticosteroids and long-acting beta2-agonists in the prevention of exacerbations in COPD

Acute exacerbations of COPD can complicate the course of the disease in patients with severe airway obstruction. Reduction of exacerbations is an important clinical outcome in evaluating new therapies in COPD. Combination therapies with long-acting beta-agonists and inhaled corticosteroids have now been approved for use. Three 1-year randomized clinical trials, which studied the effect of combining a long-acting beta2-agonist with an inhaled corticosteroid in COPD, documented that exacerbation frequency was lower with therapy than placebo. Combination therapy had a similar effect to its monocomponents in the trial evaluating salmeterol/fluticasone combination. However, when patients with more severe COPD were studied using a combination of budesonide and formoterol, a clear improvement was seen in the overall exacerbation rates compared with the use of a long-acting beta2-agonist alone.