Which medications work best for older adults with chronic obstructive pulmonary disease?
Doctors aren’t entirely sure: Despite the fact that C.O.P.D. is the third-leading cause of death, there is scant research on the comparative effectiveness of treatment options in seniors. But a study recently published in The Journal of the American Medical Association provides valuable new information.
C.O.P.D. refers primarily to two conditions that compromise breathing: emphysema and chronic bronchitis. Nearly four million seniors have been diagnosed with the condition.
For their new study, researchers in Ontario combed through records of all adults ages 66 and older with C.O.P.D. who had started taking two types of medications: long-acting beta agonists and inhaled corticosteroids.
Long-acting beta agonists (sold under brand names like Foradil, Oxis, Serevent) help relax muscles around the airways in the lungs, allowing air to flow more freely. Inhaled corticosteroids (Flovent, Azmacort, Asmanex and others) act against inflammation and swelling in airways, making breathing easier.
Clinical guidelines recommend that doctors begin treatment for C.O.P.D. with long-acting beta agonists (or another set of medications called long-acting anticholinergics, not studied in this report), then add other medications if necessary. But it has never been clear if this is optimal for older adults.
The Canadian study is the first to focus on seniors in real-world settings who tend to have lots of complications, unlike people included in gold-standard clinical trials, which tend to exclude patients with multiple medical conditions.
The researchers examined administrative health records for 2,129 older adults taking long-acting beta agonists alone and 5,594 adults taking them with corticosteroids, documenting how many in each group were hospitalized and died over a period of about two and a half years.
They found that seniors taking both medications had 8 percent fewer deaths and hospitalizations during this period, compared with those taking long-acting beta agonists alone, a result they called modest but significant.
More striking were results for seniors with asthma as well as C.O.P.D., who made up more than a quarter of the group studied. When they took the two medications instead of one, their risk of hospitalization and death was 16 percent lower, compared with people with both conditions who took only long-acting beta agonists.
Previous studies of patients with C.O.P.D. have tended to exclude people who also have asthma. “We haven’t really known how to treat these patients,” said Dr. Andrea Gershon, lead author of the study and an assistant professor of medicine at the University of Toronto.
In an accompanying editorial, Peter Calverley, a professor of pulmonary and rehabilitation medicine at the University of Liverpool, wrote, “There has been much interest in this asthma-C.O.P.D. overlap syndrome.” The study results suggest that these patients should be treated with both drugs, he added.
Dr. Barry Make, co-director of the C.O.P.D. program at National Jewish Health in Denver, speculated that older C.O.P.D. patients with asthma might experience more inflammation than younger patients. The new study confirms that “patients with C.O.P.D. tend to be very different” from one another, he said. “We really need to personalize our treatment for patients much better than we do now.”