March 23, 2011 -- Once-daily Spiriva (tiotropium) may be more effective at reducing risk for exacerbations among people with moderate to severe chronic obstructive pulmonary disease (COPD) than Serevent (salmeterol), a new study shows.
The findings are published in the New England Journal of Medicine.
COPD is the name given to a group of progressive lung diseases, including emphysema and chronic bronchitis, that makes it harder to breathe. COPD symptoms can worsen during exacerbations, so increasing the amount of time between such flares is an important part of COPD management.
Both Spiriva and Serevent are long-acting bronchodilators that open the airways, but they do so via different mechanisms.
In the one-year study of 7,376 people with moderate to very severe COPD, those who took once daily Spiriva, compared to those who took twice daily Servent, had an increased amount of time to the first exacerbation (187 days vs. 145 days). That represents a 17% reduction in risk of exacerbation.
“The results show that, in patients with moderate-to-very-severe COPD, tiotropium [Spiriva] is more effective than salmeterol [Servent] in preventing exacerbations,” conclude researchers who were led by Claus Vogelmeier, MD, of the Hospital of the Universities of Giessen and Marburg, Germany.
In an accompanying editorial, Jadwiga A. Wedzicha, MD, of the University College London Medical School, says that the new study attempts to help answer an important question regarding the treatment of COPD: which long-acting bronchodilator should be the initial choice for people with COPD.
“The trial evidence suggests that with respect to exacerbation outcomes, tiotropium, administered once daily, is superior to salmeterol, administered twice daily,” he writes.
Choosing a COPD Drug
Stephen I. Rennard, MD, the Larson Professor of Medicine in the pulmonary and critical care medicine section in the department of internal medicine at the University of Nebraska Medical Center in Omaha, agrees. “One of the major issues in COPD is which drug do you start someone on,” he says. “The new study provides evidence in terms of how to prioritize the drugs that are available if you have to choose one.”
Tiotropium is not available in combination with an inhaled steroid, but salmeterol is, he says. If someone also needs steroids, the latter may be a better option as it is simpler to administer.
Thomas Aldrich, MD, professor of medicine at Montefiore Medical Center and the Albert Einstein College of Medicine in the Bronx, N.Y., has always favored Spiriva over Serevent.
“It as good with fewer side effects,” he says. The new study does help narrow the playing field, he says.
“There is a tendency to use many drugs to treat COPD, and each one has potential side effects and costs a fortune, so if we can make a more rational choice and cut down to the ones that are most likely to be effective, it will be of tremendous benefit,” he says.
Personalized Therapy for COPD
Barry Make, MD, a pulmonologist and professor of medicine at National Jewish Health in Denver, says that the new findings may tip the scale toward starting select people with COPD on Spiriva as opposed to other long-acting bronchodilators.
But there is more to it, he says. “I look at each patient as an individual and make treatment decisions based on their particular characteristics and symptoms," he says. “If your goal is to decrease exacerbations in someone who is prone to them, Spiriva may be the right choice. But for someone who doesn’t have so many exacerbations, we may focus on symptoms instead and choose another drug.”
Len Horovitz, MD, an internist and pulmonologist at Lenox Hill Hospital in New York City, says there is more to COPD management than simply increasing time to first exacerbation.
“This is just one parameter,” he says. Others include long-term survival or disease progression and the new study does not look at these.
“It is important to have [Spiriva] on board, but it’s not the only drug that you would want to have on board,” he says.