Little evidence for using combination inhalers as first choice for patients with chronic lung disease
It is difficult to justify using the combination inhalers Seretide (fluticasone and salmeterol) or Symbicort (budesonide and formoterol) as a first choice in managing patients with chronic obstructive pulmonary disease, according to a review published in Drug and Therapeutics Bulletin this
month (2004:42;18).
The authors note that both Seretide and Symbicort cost the NHS about
the same — or possibly less — than the combined cost of their
individual components, but say that neither product has been compared
in published trials with its individual components taken concomitantly
via separate inhalers.
Anna Murphy, consultant respiratory pharmacist at Glenfield Hospital,
Leicester, told The Journal: “I agree with the need for trials
but cannot envisage the drug companies funding them.”
Although Seretide (Allen & Hanburys) has been shown to improve lung
function more than either of its constituents alone and may reduce breathlessness,
the authors of the DTB review say there is no published evidence that
it is any more effective at preventing COPD exacerbations than salmeterol
or fluticasone given alone. They add that this weakens the advertising
claim that the treatment reduces the risk of exacerbations, which relates
only to comparison with placebo.
A spokeswoman for Allen & Hanburys told The Journal that the improvements
in breathlessness seen in trials with Seretide 500 were not given enough
prominence in the bulletin. She pointed out that these data have contributed
to National Institute for Clinical Excellence COPD
guidelines (PJ, 28
Februry p239) and have been taken into account by the Scottish Medicines
Consortium in its unrestricted recommendation for Seretide in COPD.
The DTB authors acknowledge that Symbicort (AstraZeneca) improves lung
function more than budesonide alone, but they say that evidence for its
effects compared with formoterol is conflicting. Symbicort reduces exacerbation
rates more than formoterol, but not more than budesonide and it increases
the time to first exacerbation more than either budesonide or formoterol
taken alone. The authors say that there is conflicting evidence about
whether Symbicort improves quality of life, and add that it does not
appear to improve total symptom scores more than formoterol taken alone.
Mrs Murphy said: “The trials for both Symbicort and Seretide show
a limited increase in the mean FEV1 [a lung function test] when compared
with the long-acting beta2-agonist alone. As this is a mean value some
patients will have a more substantial improvement in FEV1 than others.
This highlights again the importance of medication review.” She
added: “A logical, stepwise approach to the management of COPD
patients as suggested by the NICE guidelines should be employed, reviewing
efficacy and tolerability of treatments.” |
The
Pharmaceutical Journal