Initial treatment of COPD with LABA-ICS or LABA-LAMA: real-world comparative effectiveness

Area of Science:

• Pulmonology
• Pharmacology
• Real-world evidence

Background:

• Current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend LABA-LAMA for initial COPD treatment in patients with multiple exacerbations.
• These recommendations are based on trials that excluded patients with multiple prior exacerbations, questioning their applicability to this specific population.
• The comparative effectiveness of LABA-ICS versus LABA-LAMA as initial therapy, especially in high-exacerbation COPD patients, remains unclear in real-world settings.

Purpose of the Study:

• To compare the real-world effectiveness of initiating COPD treatment with LABA-ICS versus LABA-LAMA inhalers.
• To specifically investigate this comparison in patients experiencing multiple COPD exacerbations.
• To evaluate the incidence of moderate or severe COPD exacerbations within one year of treatment initiation.

Main Methods:

• A cohort of over 37,000 adult COPD patients initiating treatment with either LABA-ICS or LABA-LAMA were identified from the UK Clinical Practice Research Datalink.
• Patients were treatment-naïve for asthma, LABA, LAMA, or ICS.
• Propensity score weighting was used to adjust for baseline differences and compare the incidence of moderate or severe exacerbations over one year.

Main Results:

• Initiating LABA-ICS was associated with a similar overall risk of exacerbation compared to LABA-LAMA (adjusted HR 1.03).
• However, in patients with two or more prior exacerbations, LABA-ICS showed a reduced risk of exacerbation (HR 0.89).
• Conversely, LABA-ICS was associated with an increased risk in patients with no prior exacerbations (HR 1.07) and a reduced risk in those with FEV1 ≥50% predicted (HR 0.92).

Conclusions:

• Initiating COPD therapy with LABA-ICS may be more effective than LABA-LAMA in patients with multiple exacerbations, particularly those with FEV1 ≥50% predicted.
• LABA-LAMA may be more effective for patients with no prior exacerbations and FEV1 <50% predicted.
• These findings support a personalized, targeted approach to selecting initial pharmacotherapy for COPD based on exacerbation history and lung function.