Nicola Hanania, MD, MS: Combination Therapies in COPD

Sometimes 2 is better than 1, and in the case of treatments for chronic obstructive pulmonary disease (COPD), combination therapies may be more effective.

While at the 2018 CHEST Annual Meeting in San Antonio, TX, Nicola Hanania, MD, MS, director of the Airways Clinical Research Center at Baylor College of Medicine, spoke with MD Magazine^® to explain the latest research on COPD treatments and outlines how they all measure.

MD Mag: How effective are combination therapies for COPD?

Hanania: The LABA/LAMA (indacaterol and glycopyrronium) combination—that concept is not new. For many years, we have used short-acting beta2 agonists and short-acting anticholinergic put together. Pharmacologically, it makes sense because they work through different mechanisms.

The beta agonists activate the beta 2 receptor, and the anticholinergics block the N3 receptor on

the smooth muscle.

When you put 2 together, naturally, you get a better effect. In fact, some studies not suggest that there may be synergistic effect, meaning 1 plus 1 is not only 2, but maybe 3. There may be a potentiation of effect when you put them together.

What do clinical trials show? They do show that they improve lung function and symptoms—compared to 1 drug alone. They [also] improve exercise tolerance.

There’s a very nice study published in the last year looking at cardiovascular function in these hyperinflated patients— COPD patients have hyper inflation, which can put pressure on the heart so that the heart function is not as normal.

In 1 study, they showed that using the LABA/LAMA, or a combination drug, can actually improve cardiovascular function. Their [combination therapies] may go beyond the lung.

One of the big questions is whether they [combination therapies] reduce exacerbations compared to just 1 long-acting bronchodilator alone. There are studies that are conflicting.

Some studies show yes [they do reduce exacerbations], and some studies show maybe.

Also, there are studied comparing LABA/LAMA with LABA and inhaled cortical steroids (ICS) combinations, which are another type of combinations available. Some of these studies show superiority to LABA/LAMA therapies over LABA/ICS.

I still believe some patients with COPD definitely benefit from inhaled cortical steroids in a combination. That groups of patients includes the high exacerbators. Maybe those patients with high blood eosinophils, which is a biomarker that predicts exacerbation in these patients, possibly respond to ICS.

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