Chest
Volume 137, Issue 2, February 2010, Pages 318-325
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Original Research
COPD
Inhaled Corticosteroids vs Placebo for Preventing COPD Exacerbations: A Systematic Review and Metaregression of Randomized Controlled Trials

https://doi.org/10.1378/chest.09-1305Get rights and content

Background

Inhaled corticosteroids (ICS) have been shown to decrease the occurrence of COPD exacerbations. However, the relationship of baseline lung function and reduction of exacerbations with the use of ICS remains unknown. Herein, we perform a metaregression to evaluate the efficacy of ICS in preventing COPD exacerbations.

Methods

We searched the PubMed, EmBase, and Cochrane Central Database of Controlled Trials databases (1988-2008) for studies that have reported the efficacy of ICS vs placebo in preventing COPD exacerbations. We pooled the risk ratio (RR) and 95% CIs from individual studies using a random-effects model to assess the exacerbations in the two groups. We also performed a weighted random effects metaregression using baseline FEV1 values.

Results

Our search yielded 11 studies (8,164 patients). The use of ICS was associated with reduction in the occurrence of exacerbations (RR, 0.82; 95% CI, 0.73–0.92). There was the presence of significant statistical heterogeneity but no evidence of publication bias. Sensitivity analysis revealed benefit of ICS only in patients with FEV1 < 50% (RR, 0.79; 95% CI, 0.69–0.89) with persistence of statistical heterogeneity. Metaregression showed that the percentage risk reduction in exacerbations with the use of ICS is invariant across the severity of COPD (assessed by FEV1).

Conclusion

There is only a modest benefit of ICS in preventing COPD exacerbations, which is not related to the level of baseline lung function on metaregression analysis. The benefits of ICS in preventing COPD exacerbations thus seem to be overstated.

Section snippets

Search Strategy and Selection Criteria

To identify the studies for inclusion in this review, all the authors independently searched the computer databases PubMed, Cochrane Central Database of Controlled trials, and EmBASE for relevant studies published from 1988 to 2008 using free text terms: inhaled corticosteroids, ICS, chronic obstructive pulmonary disease, and COPD, in various combinations, and limiting the search to English literature. Bibliographies of all selected articles and review articles that included information on the

Results

Our initial database search retrieved 1,095 citations (Fig 1). Of these, 177 studies were excluded as they did not involve COPD. Finally, 11 studies (8,164 study participants; 4,241 ICS, 3,923 placebo) that met our inclusion criteria were included in the final analysis.27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 All the studies were prospective, double-blind, randomized, placebo-controlled trials. The Jadad score was greater than three for all the studies, indicating high quality of the

Discussion

The results of this systematic review suggest that there is a modest relative risk reduction in COPD exacerbations with the use of ICS. In the sensitivity analysis, the beneficial effect was noted only in patients with FEV1 values less than 50%. There was presence of significant statistical heterogeneity with no evidence of publication bias. A metaregression analysis also failed to demonstrate a linear relationship between FEV1 values and decline in COPD exacerbations with the use of ICS.

The

Acknowledgments

Author contributions: Dr Agarwal: contributed to literature search, data analysis, and drafting of the manuscript.

Dr Aggarwal: contributed to literature search, data analysis, and drafting of the manuscript.

Dr Gupta: contributed to literature search and drafting of the manuscript.

Dr Jindal: contributed to literature search and drafting of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any

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