Clinical Medicine Reviews in Therapeutics

Tiotropium bromide (TIO), a long-acting anticholinergic bronchodilator, is now used world-wide for the treatment of Chronic Obstructive Pulmonary Disease (COPD). However, the GOLD guidelines recommend another, or additional medication for symptomatic patients with GOLD stage III or IV disease, forced expiratory volume in 1 second (FEV1) less than 50% of the predicted value, and repeated exacerbations. Several lines of evidence such as the TRISTAN study have shown the synergistic effects of a salmeterol–fluticasone propionate combination (SFC), with significant improvements of pulmonary function, health status, exacerbation rates, and quality of life in patients with COPD, compared with using individual components of SFC. But they didn’t obtain any improvement in the data for mortality, which is our major clinical concern. The TORCH study is a major study which investigated all-cause mortality rates, but it showed no significant difference of mortality among SFC, individual drugs and placebo groups. The INSPIRE study showed significant improvement of mortality in the SFC treatment group, compared with the TIO. However, the higher incidence of pneumonia in the SFC group remains a subject of debate. Some studies showed that SFC therapy has lower medical costs with good patient compliance, which may become a reason for choosing the therapy.

The new 2010 NICE GOLD Guideline recommends the “triple” therapy with SFC and TIO, when the FEV1% predicted is less than 50% in the presence of persistent exacerbations or breathlessness. The advantages of “triple” therapy may outweigh the disadvantages of each medication. This review focuses upon the therapeutic potential of SFC for the treatment of COPD.