Effects of Advair® in Outpatients With Chronic Obstructive Pulmonary Disease (COPD) Acute Exacerbation

COPD exacerbations are a common cause of ill health, hospitalization and death. Once exacerbation symptoms are recognized, the current treatment consists of short course of oral steroids, antibiotics and increased bronchodilator intake. Systemic steroids are thought to reduce the inflammatory component of COPD exacerbation. A short course of steroid therapy improves FEV1 and decreases the relapse rate but most studies have been done on patients requiring hospitalization. Only few studies have described the role of steroids in the outpatients setting. However, some concerns remain about using systemic steroids for all patients with acute exacerbation. Their short-term advantages may be outweighed by the occurrence of adverse side effects such as hyperglycemia, which is difficult to manage on an outpatient basis. In this context, the possibility of treating patients with COPD exacerbation with inhaled steroids having less systemic adverse effects is interesting. In clinical trials, combination of corticosteroid with long-acting β2-adrenoceptor agonists (LABA) reduces airway inflammation, exacerbation rates, and improves lung function and health status of patients with stable moderate to severe COPD beyond that achieved by individual component therapy. Trials showed that nebulized steroid during acute COPD exacerbation requiring hospitalization is as effective as prednisone with less hyperglycemia. To our knowledge, no study has been conducted on the efficacy of combination treatment with inhaled steroid and LABA in the outpatient management of COPD exacerbation. Combination treatment could be a good alternative for patients with steroid contraindication and to reduce hospitalisation for uncontrolled hyperglycemia.

Primary objective: To compare relapse rates, lung function, the severity of dyspnea and, systemic and sputum inflammatory markers in outpatients with acute exacerbations of COPD treated with twice the regular dosage of Advair® or oral prednisone for 10 days.

Secondary objectives: To obtain preliminary data allowing sample size calculation for a larger similar clinical trial.

Hypothesis: Advair® is as effective as oral prednisone in treatment of outpatients with an acute COPD exacerbation.

Airway inflammation is a component of the pathophysiology of COPD exacerbation. Sputum from COPD-exacerbation patients has elevated inflammatory cells, TNF, IL-8 and RANTES levels compared to stable patients. Systemic steroid are thought to reduce the inflammatory component of COPD exacerbation. Appraisal of the current literature on glucocorticosteroids for acute COPD exacerbation show that a short course of systemic corticosteroid therapy improves spirometry and decreases the relapse rate but most studies using steroids for exacerbation have been done on patients requiring hospitalization, and only few have described the role of steroids in the outpatients setting. Two randomized controlled trials studied patients with acute COPD exacerbations not requiring hospitalization. Patients were assigned to receive oral prednisone for at least 9 days or placebo. The prednisone group showed a more rapid and significant improvement in forced expiratory volume at one second (FEV1). This therapy also resulted in fewer treatment failures and a trend toward more rapid improvement in dyspnea scale scores compared to placebo. However, despite proof of efficacy, some concerns remain about using systemic corticosteroid for all patients with acute exacerbation. Mainly because the short-term advantage may be outweighed by the occurrence of adverse side effects such as hyperglycemia, which is difficult to manage on outpatient basis and myopathy that can be observed even following a single oral dose of prednisolone. In this context, the possibility of treating patients with acute COPD exacerbation with inhaled corticosteroid having less systemic adverse effects is on particular interest.

Two trials have studied the effect of nebulized steroid during acute COPD exacerbation requiring hospitalization. Maltais et al. showed that 3 days of oral prednisone or nebulized budesonide significantly increased FEV1 compared to placebo. Compared with prednisone, nebulized budesonide was associated with a lesser occurrence of hyperglycemia, a potential advantage for diabetic patients with COPD. Recent studies have suggested long-acting b2-agonist as potential option in the treatment of acute exacerbation of COPD. It has been shown that salmeterol (up to 100 mcg) as formoterol (up to 48mcg) given over the same interval time induced an effective dose-dependent increase in FEV1, FVC and IC in patients with mild acute COPD exacerbation. Finally, the inhaled combination of salmeterol/fluticasone during 13 weeks in stable COPD patients showed a significant decrease in airway inflammation with decrease of lymphocytes, neutrophils, eosinophils and cells expressing genes for TNF and IFN. The main effect of inhaled corticosteroids is thought to be mediated through suppression of airway inflammation, while LABA are thought to work by inducing bronchodilation. However, there is emerging data to indicate that long-acting b2-adrenoceptor agonists may amplify the anti-inflammatory effects of corticosteroids by accelerating nuclear translocation of the glucocorticoid receptor complex, and enhancing transcription and expression of steroid-inducible genes in pro-inflammatory cells. These results suggest a role of the combination of long-acting b2-adrenoreceptor agonist and inhaled steroid in the inflammation observed in acute COPD exacerbation.