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LABA+LAMA+ICS associated with greater decline in all-cause mortality than LABA+LAMA in patients with severe COPD (IMPACT)
Clinical Question
Is triple therapy in patients with moderate or severe chronic obstructive pulmonary disease (COPD) associated with greater reductions in all-cause mortality than dual therapy?
Bottom line
In this secondary analysis of the IMPACT study, the use of triple therapy - an inhaled corticosteroid (ICS) plus a long-acting muscarinic antagonist (LAMA) plus a long-acting beta agonist (LABA) - was associated with lower all-cause mortality than dual therapy with either LAMA plus LABA or ICS plus LABA. We recently reviewed the American Thoracic Society guideline that recommends starting with LAMA plus LABA and adding ICS for 1 year in patients with exacerbations or ongoing breathlessness. 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Industry
Setting: Outpatient (specialty)
Synopsis
To allow gathering vital status on the participants, these authors conducted a secondary analysis of the IMPACT study, which enrolled 10,355 patients with severe chronic obstructive pulmonary disease (COPD) based on spirometry who also had at least 1 moderate or severe exacerbation in the previous year or with moderate COPD plus 2 or more moderately severe exacerbations or 1 severe exacerbation in the preceding year. Following a 2-week run-in period during which the patients continued their usual treatment, the researchers randomized patients to receive once-daily triple therapy (n = 4151) or 1 of 2 types of dual therapy. Triple therapy consisted of an ICS (fluticasone furoate) plus a LAMA (umeclidinium) plus a LABA (vilanterol), commercially available in the United States as Trelegy. The 2 forms of dual therapy were a combination of an ICS plus a LABA (Breo; n = 4134) or a LAMA plus a LABA (Anoro; n = 2070). As near as I can tell, the authors put each combination into the same delivery device. After 1 year, they report that 98 (2.4%) patients who received triple therapy died compared with 109 (2.6%) patients who received ICS plus LABA, and 66 (3.2%) of those receiving LAMA plus LABA.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI