The IMPACT trial; What do we do about inhaled steroids in COPD?


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“B” is for Bias!

Pity inhaled steroids. Once a favored drug in the treatment of COPD, they were initially advocated to be used in combination LABA’s (long acting beta agonists) to have a “protective” effect against the harms of LABA’s which were,, back  in the day, proposed to have existed in the SMART trial. Things of course have change quite a bit since then. The black box warning for combination inhalers has since been dropped. Ironically it’s now the inhaled steroids that we worry about in the treatment of COPD, as mounting evidence implicates inhaled steroids as increasing the risk of pneumonia.

In the most recent GOLD update, steroids have been relegated as add on therapy to LABA for patients with an exacerbation. However GOLD recommends LABA/LAMA combination as preferred due to evidence that the combination reduces exacerbations better than LABA/ICS, as demonstrated in the FLAME trial. In fact ICS is recommended only as add-on therapy to LABA/LAMA in patients who are highly symptomatic and at high risk of exacerbations.

The Impact trial may be changing that. It compared a single inhaler triple therapy LABA/LAMA/ICS to dual combinations of LABA/LAMA and LABA/ICS. Interestingly, and also quite confusingly, the triple therapy group had reduced exacerbations and reduced COPD related hospitalizations. These results are of course in conflict with the results of the Wisdom Trial, which saw no significant difference in the rate of exacerbations between LABA/LAMA combination vs. triple therapy with LAMA/LAMA/ICS. GSK, of course, has wasted no time telling us this,  touting the results of their newest inhaler far and wide. Continue reading “The IMPACT trial; What do we do about inhaled steroids in COPD?”