February 8th, 2010 | 
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Yes, that is a crystal studded MDI....
A recent paper in Chest has suggested that the staple treatment for COPD may not be the knees of the bees after all. Inhaled corticosteroids (ICS) have been the cornerstone of COPD management for some time, with the aim of reducing inflammation and (hopefully) cutting exacerbation rate. The TORCH study successfully did away with thoughts of ICS improving survival (ahh, the agony of p=0.052) but at least we have the principle of symptom control to cling to don’t we? Well, don’t we?
The clever bods from Chandigarh, India have taken 11 large prospective, double-blind, randomized, placebo-controlled trials and passed it through their Metaregression-ometer and come up with the conclusion that “The benefits of ICS in preventing COPD exacerbations seems to be overstated”. The collected statistics from the 8,164 patients pooled from seminal papers including ISOLDE, TRISTAN and TORCH showed that “we did observe a modest benefit of ICS in preventing COPD exacerbations in patients with FEV 1 < 50%. However, this finding was not further substantiated on a metaregression analysis wherein we did not observe a significant effect of baseline values of FEV 1 (percentage predicted) on the benefits from ICS compared with placebo. Thus, ICS is likely to have only modest benefits in preventing COPD exacerbations, if at all, and should be judiciously used in patients with COPD keeping in mind the risk-benefit ratio.”
I’ll admit my utter ignorance of the nuances of metaregression analysis and its potential flaws when used like this, but I would hope that the use of words such as “likely” and “modest” would hint that the analysis has scope to be challenged by people with more statistical savvy than my good self. Mind you, it doesn’t really matter does it, what with the veritable panacea of COPD drugs at our disposal…………(right, anyone got shares in Roflumilast?).
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My faith in meta-analysis is shaky, at best. We’ve seen how the CP3O trial showed that CPAP isn’t quite the mutt’s nuts in heart failure as we all thought, despite the meta-analyses showing CLEARLY that it’s the business. I seem to recall Magnesium in acute MI being similarly lauded, then dismissed.
Sim showed in his meta-analysis of the same datasets that there is a mortality benefit with ICS, the Soriano data shows the same thing, over a longer period.
But, we’ve known for 10 years that steroids alone are of no use in COPD – even Romain Pauwells accepted it, despite his own data suggesting otherwise. The interest is surely in combination therapy?
Allan Morice gave a talk I was at the other day:he was utterly convinced that the way forward is simple unopposed bronchodilatation, with no steroid. But just ask Bill MacNee what he thinks of that….
Prof Morice is certainly an interesting talker with interesting ideas, but bronchodilation alone? Hmmm…
My problem with meta-analysis is I have a grasp of the basics but struggle to understand the process or be able to pick holes in it when reading the paper, especially when they start using meta-regression-analysis…..whatever the hell that is.