Long-acting muscarinic antagonists + inhaled steroids = long-acting B-agonists + inhaled steroids

Référence

Sobieraj DM, Baker WL, Nguyen E, et al. Association of inhaled corticosteroids and long-acting muscarinic antagonists with asthma control in patients with uncontrolled, persistent asthma. A systematic review and meta-analysis. JAMA 2018;319(14):1473-1484.

Sommaire

Since 2014 a number of LAMAs (eg, tiotropium/Spiriva, umeclidinium/Incruse, aclidinium/Tudorza) have been marketed for the treatment of asthma. These investigators thoroughly searched multiple sources, including MEDLINE, EMBASE, the Cochrane databases, clinical trial registries, manufacturers' data, and bibliographic references, for studies that compared LAMA therapy with placebo or other controllers as an add-on therapy to ICS in patients at least 12 years old with uncontrolled persistent asthma. No language restrictions were applied. Two reviewers independently evaluated potential studies for inclusion and used a standard scoring tool to assess methodologic quality. Disagreements were resolved by consensus discussion with a third reviewer. A total of 15 randomized controlled trials (N = 7122 patients) met inclusion criteria. Of these, 3 received a high risk of bias score, with the remaining scoring at low risk of bias. Adding a LAMA to ICS compared with adding placebo was significantly associated with a reduced risk of asthma exacerbation requiring systemic corticosteroids (relative risk 0.67; 95% CI 0.48-0.92). There was, however, no significant differences in rescue medication use or quality of life scores between add-on LAMA therapy and add-on placebo. When comparing LAMA to LABA as add-on therapy to ICS, there was no significant difference in risk of asthma exacerbation requiring systemic corticosteroids, rescue medication use, or quality-of-life scores. Triple therapy with LAMA, LABA, and ICS was not superior to LABA plus ICS. Limiting the analysis to only studies with a low risk of bias did not change the results. A formal analysis for publication bias was not possible because of the small number of studies. Formal testing found minimal evidence of significant heterogeneity of results.