Response

Abstract

We thank Lipworth et al for their comments on our real-world data study1Suissa S. Dell'Aniello S. Ernst P. Comparative effects of LAMA-LABA-ICS vs LAMA-LABA for COPD: cohort study in real-world clinical practice.Chest. 2020; 157: 846-855Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar of the comparative effects of long-acting muscarinic antagonist (LAMA)-long-acting beta2-agonist (LABA)-inhaled corticosteroid (ICS) vs LAMA-LABA in COPD. Our study finds that LAMA-LABA-ICS shows greater effectiveness at reducing the incidence of exacerbations than LAMA-LABA exclusively in patients with significant eosinophilia or with frequent exacerbations. For all other patients, effectiveness of triple therapy with LAMA-LABA-ICS was no different than with LAMA-LABA, except for a higher incidence of pneumonia with triple therapy. Unfortunately, the additional analysis suggested by Lipworth et al on the joint group of patients with both high eosinophilia and frequent exacerbations is simply unviable in our study because of the limited strata sizes. Indeed, with only 130 patients with > 6% eosinophil count and 361 with two or more exacerbations among the users of LAMA-LABA, the combination of these two factors would lead to trivial sample sizes. The limited sample sizes also do not allow for the suggested analysis using eosinophil count as a continuous variable. We agree with Lipworth et al that our study is based on data when LAMA-LABA-ICS triple therapy was available as two separate inhalers, as were most of the dual LAMA-LABA bronchodilators used in the comparator group. It will certainly be valuable and informative to repeat these studies when single inhaler double and triple therapies are more widely available because adherence may improve with such formulations. In all, more such studies in real-world settings of clinical practice are needed to better characterize the use, effectiveness, and safety of these medications. Observational Data With Inhaled Corticosteroid/Long-Acting Beta-Agonist/Long-Acting Muscarinic Antagonist May Not Reflect Current Practice With Single Triple InhalersCHESTVol. 157Issue 4PreviewWe read with interest the observational data of the recent study by Suissa et al1 in this issue of CHEST, which suggested superior real-world benefits of taking inhaled corticosteroid (ICS) with long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) over LABA/LAMA in patients with COPD with blood eosinophil count > 6%, or in those with at least two exacerbations in the past year. Previous post hoc analysis of Calverely et al2 showed that the effect of ICS withdrawal from preexisting triple therapy resulted in 43% increased exacerbations in those patients who had at least two previous exacerbations who also had a eosinophil count > 4% (ie, > 300 cells/μL). Full-Text PDF Comparative Effects of LAMA-LABA-ICS vs LAMA-LABA for COPD: Cohort Study in Real-World Clinical PracticeCHESTVol. 157Issue 4PreviewTriple therapy combinations of a long-acting muscarinic antagonist (LAMA), a long-acting beta2-agonist (LABA), and an inhaled corticosteroid (ICS) for COPD were studied in randomized trials and observational studies, with variable results. We compared the effectiveness and safety of triple therapy with a LAMA-LABA combination in a real-world clinical practice setting. Full-Text PDF