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Article pour les cliniciens

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La trithérapie dans la gestion de la maladie pulmonaire obstructive chronique: une revue systématique et méta-analyse.

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• Zheng Y
• Zhu J
• Liu Y
• Lai W
• Lin C
• Qiu K, et al.

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Commentaires cliniques (en anglais)

Family Medicine (FM)/General Practice (GP)

These data need some conversion to absolute risk differences before they can be adopted wholesale, but triple therapy does seem to reduce acute exacerbations.

Family Medicine (FM)/General Practice (GP)

Triple therapy has been used in the management of COPD for quite some time without the necessary evidence. This new review provides that evidence for COPD patients with severe disease. The study does point out the increased risk for pneumonia with inhaled steroids. It also points out that patients with more "asthmatic" features might benefit more from triple therapy. Physicians should continue to carefully select the patients who receive triple therapy. LABA and LAMA should still be first-line therapy for COPD patients.

Family Medicine (FM)/General Practice (GP)

As reported in this meta-analysis, there is pretty robust evidence that triple therapy for COPD results in fewer exacerbations, better spirometry values, and probably higher quality-of-life. This study's authors caution, however, that triple therapy should not be first-line therapy. They state, "triple therapy did not improve patients’ survival, and could increase the risk of pneumonia. Therefore, triple therapy should be limited to patients with more severe COPD." Additionally, the way the results are reported in this review precludes calculation of the absolute risk reduction (so no NNT can be calculated). So, if the risk of exacerbation is not large, the benefit from triple therapy will be small.

General Internal Medicine-Primary Care(US)

This review underscores the need for triple therapy in COPD.

General Internal Medicine-Primary Care(US)

A very nice summary. One of the main take-away points is emphasized in reference 39: We should be sure patients know how to use inhalers well.

Respirology/Pulmonology

Meta-analysis suggests benefit of triple therapy for COPD compared with monotherapy with LAMA or ICS/LABA. This is similar to the results of the IMPACT trial published this year. As with other studies, there is a slight increase in pneumonia risk with ICS use. Hopefully, studies will be done to help determine which COPD patients would benefit the most from this therapy and which would not.

Respirology/Pulmonology

This meta-analysis shows that triple therapy is superior to LABA/LAMA, ICS/LABA, or LAMA alone for reducing COPD exacerbations. Nearly all of the individual trials found this on their own, so this is already known to most clinicians. The meta-analysis adds little new information. There is moderate-to-high heterogeneity among trials that the authors did not explain (for example, whether patients exacerbate frequently at baseline or not is likely relevant).

Respirology/Pulmonology

The GOLD guidelines recommend triple therapy for patients with COPD who still suffer exacerbations on a LABA/LAMA combination. This analysis confirms the recommendation.