Beclometasone for chronic obstructive pulmonary disease.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic obstructive lung condition, diagnosed in patients with dyspnoea, chronic cough or sputum production and/or a history of risk factor exposure, if their postbronchodilator forced expiratory lung volume in 1 second (FEV1)/forced vital lung capacity (FVC) ratio is less than 0.70, according to the international GOLD (Global Initiative for Obstructive Lung Disease) criteria.Inhaled corticosteroid (ICS) medications are now recommended for COPD only in combination treatment with long-acting beta2-agonists (LABAs), and only for patients of GOLD stage 3 and stage 4 severity, for both GOLD groups C and D.ICS are expensive and how effective they are is a topic of controversy, particularly in relation to their adverse effects (pneumonia), which may be linked to more potent ICS. It is unclear whether beclometasone dipropionate (BDP), an unlicensed but widely used inhaled steroid, is a safe and effective alternative to other ICS.

OBJECTIVES

To determine the effectiveness and safety in COPD of inhaled beclometasone alone compared with placebo, and of inhaled beclometasone in combination with LABAs compared with LABAs alone.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) (includes Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearching of respiratory journals and meeting abstracts) (February 2013), conference abstracts, ongoing studies and reference lists of articles. We contacted pharmaceutical companies and drug marketing authorisation bodies/ethics committees in 49 countries and obtained licensing information.

SELECTION CRITERIA

Randomised controlled trials of BDP compared with placebo, or BDP/LABA compared with LABA, in stable COPD. Minimum trial duration is 12 weeks.

DATA COLLECTION AND ANALYSIS

Inclusion, bias assessment and data extraction were conducted by two review authors independently. The analysis was performed by one review author. Study authors were contacted to obtain missing information.

MAIN RESULTS

For BDP versus placebo, two studies were included, of which one trial (participants n = 194) was included in the quantitative analysis. This study was a very high-dose trial with stable stage 2 and 3 COPD participants. No statistically significant results in change in lung function, mortality, exacerbations, dyspnoea scores or withdrawal were obtained. The quality of the evidence of all these outcomes was graded low to very low. Data on risk of pneumonia were lacking.The main focus of the review was the more clinically relevant BDP/LABA versus LABA arm. Therefore the findings are reported more fully.For BDP/LABA versus LABA, one study (n = 474) was included, with a further ongoing study identified for future inclusion. The included trial was a high-dose study of stable stage 3 COPD participants. Compared with LABA, people receiving BDP/LABA showed a statistically significant improvement in FEV1 lung function measurements of 0.051 L (95% confidence Interval (CI) 0.001 to 0.102, P = 0.046) (high quality of evidence) and in (self-reported) days without rescue bronchodilators (mean difference 7.05, 95% CI 0.84 to 13.26, P = 0.03) (low quality), both of which are unlikely to be clinically significant. Participants receiving BDP/LABA also had a statistically significant increased rate of exacerbations leading to hospitalisation (risk ratio (RR) 1.84, 95% CI 1.17 to 2.90, P = 0.008) (moderate quality), although this finding is debatable as this study's post hoc analysis showed no statistically significant difference when accounting for country-specific differences in hospitalisation policies. We did not find statistically significant differences for mortality (very low quality), pneumonia (low quality), exacerbations, exercise capacity, quality of life and dyspnoea scores, adverse events and withdrawal (all moderate quality).

AUTHORS' CONCLUSIONS: We found little evidence to suggest that beclometasone is a safer or more effective treatment option for people with COPD when compared with placebo or when used in combination with LABA; when statistically significant differences were found, they mostly were not clinically meaningful or were based on data from only one study. The review was limited by an inability to obtain data from one study and likely publication bias for BDP versus placebo, and by the inclusion of one study only for BDP/LABA versus LABA. An ongoing study of BDP/LABA versus LABA may have a further impact on these conclusions.