Copyright #ERS Journals Ltd 2000 Eur Respir J 2000; 15: 878±885 European Respiratory Journal Printed in UK ± all rights reserved ISSN 0903-1936 Long-term treatment of chronic obstructive pulmonary disease with salmeterol and the additive effect of ipratropium J.A. van Noord*, D.R.A.J. de Munck**, Th.A. Bantje***, W.C.J. Hop+, M.L.M. Akveld++, A.M. Bommer++ Long-term treatment of chronic obstructive pulmonary disease with salmeterol and the Depts of Respiratory Diseases, *Atrium additive effect of ipratropium. J.A. van Noord, D.R.A.J. de Munck, Th.A. Bantje, W.C.J. medisch centrum, Heerlen, **St Joseph Hospital, Veldhoven and ***Ignatius Hos- Hop, M.L.M. Akveld, A.M. Bommer. #ERS Journals Ltd 2000. + ABSTRACT: The efficacy and safety of salmeterol alone was compared with the pital, Breda, Dept of Epidemiology and Biostatistics, Erasmus University, Rotter- combination of salmeterol plus ipratropium and with placebo during long-term dam and ++GlaxoWellcome, Zeist, the treatment in patients with stable chronic obstructive pulmonary disease. In addition, Netherlands. the single-dose effect in response to the first dose of treatment was studied over 12 h. The patients (n=144; age 647 yrs, forced expiratory volume in one second (FEV1) Correspondence: J.A. van Noord, Dept of 4411% pred) participated in a three-centre double-blind double-placebo parallel Respiratory Diseases, Atrium medisch group study and were randomized after a run-in period of 2 weeks to receive either centrum, Henri Dunantstraat 5, 6419 PC salmeterol 50 mg b.i.d., salmeterol 5 mg b.i.d. plus ipratropium 40 mg q.i.d. or placebo Heerlen, The Netherlands. Fax: 31 for a period of 12 weeks. 455767534. The single-dose study demonstrated that salmeterol produced a significant increase Keywords: Chronic obstructive in FEV1 (peak of 7% pred) and specific airway conductance (sGaw) (maximum of 60% pulmonary disease baseline) for $12 h. The combination of salmeterol plus ipratropium elicited a greater ipratropium bronchodilator response (11% and 94% increases respectively) than salmeterol alone salmeterol during the first 6 h after inhalation. During treatment there were significant improvements in daytime symptom scores and morning peak expiratory flow in both Received: March 19 1998 the salmeterol and the salmeterol plus ipratropium groups (p<0.001), with an Accepted after revision November 7 1998 associated decrease in the use of rescue salbutamol. Improvements in FEV1 and sGaw were greater in the salmeterol plus ipratropium group than in the patients receiving only salmeterol. Thirty-five patients had an exacerbation; 11 (23%) in the salmeterol group (versus placebo NS), six (13%) in the salmeterol plus ipratropium group (versus placebo p<0.01) and 18 (36%) in the placebo group. In conclusion, in patients with severe stable chronic obstructive pulmonary disease, long-term treatment with either salmeterol alone or salmeterol plus ipratropium is safe and effective. There was added benefit from the combination therapy in terms of improvement in airways obstruction, but not for improvement in symptom control or need for rescue salbutamol. Eur Respir J 2000; 15: 878±885. Chronic obstructive pulmonary disease (COPD) is defi- salmeterol produced an improvement in lung function and ned as a disease state characterized by the presence of daily symptom scores and was associated with a clinically airflow obstruction, due to chronic bronchitis or emphy- significant gain in quality of life [7±10]. Recently MAHLER sema, and is generally progressive but may be partially et al. [11], comparing inhaled salmeterol and ipratropium reversible [1]. The goals of pharmacotherapy in this dis- in patients with COPD over a 12-week period, found that order are to induce bronchodilation and facilitate expec- salmeterol was better than ipratropium at improving lung toration in order to improve symptoms, prevent recurrent function. To date, long-term studies on combination ther- exacerbations and so enhance the quality of life [2]. In apy with salmeterol and ipratropium bromide are not patients with stable COPD, the spirometric response to available. A number of trials have shown that, in patients bronchodilators such as b2-agonists, anticholinergic drugs with stable COPD, the combination of short-acting b2- and methylxanthines is at best very modest. However, even agonists and ipratropium may be beneficial [12], and the in the absence of significant bronchodilation, an improve- combination of salmeterol and ipratropium may have ment in symptoms and exercise tolerance can be demon- additive effects and long-term benefits. strated [3]. This study was designed to compare the efficacy and Salmeterol xinofoate, a long-acting b2-agonist, has been safety of salmeterol either alone or in combination with shown in single-dose studies to induce a spirometric im- ipratropium bromide with that of placebo during a 12-week provement over a 12-h period in patients with COPD [4± treatment period in patients with stable COPD. In addition, 6]. In addition, three studies in patients with COPD over the single-dose effect in response to the first dose of the periods of 1±3 months have found that treatment with treatment was studied over a period of 12 h. SALMETEROL VERSUS SALMETEROL PLUS IPRATROPIUM IN COPD 879 Methods Measurements First dose of treatment. Airway resistance (R ), specific Patients aw airway conductance (sGaw), FEV1 and FVC were obtained Patients had to meet the following criteria to be recruited at baseline and 0.5, 1, 2, 3, 4, 5, 6, 8, 10 and 12 h after in- for the study: 1) current or exsmokers with a smoking his- halation of the trial drugs. FEV1 and FVC were recorded at tory equivalent to 10 pack-yrs and with COPD according to the mouth using a pneumotachograph with electronic inte- American Thoracic Society criteria [1]; 2) aged 40±75 yrs; gration. The best of three adequate measurements was 3) no change in medication for COPD in the preceding 6 retained. Raw and sGaw were measured in a pressure-comp- weeks and no major changes in smoking habits during the ensated integrated flow plethysmograph (SensorMedics last 6 months; and 4) a forced expiratory volume in one 2800 Autobox; SensorMedics Corp., Yorba Linda, CA, second (FEV1)of#75% of the predicted value after in- USA) as the slopes of the chords between inspiratory and halation of 200 mg salbutamol via metered dose inhaler expiratory flows of 0.5 L.s-1 at a respiratory frequency of (MDI). Exclusion criteria included the following: a his- 0.5 Hz. The means of three measurements are reported. In tory of asthma, allergic rhinitis, atopy or a total blood addition blood pressure and cardiac frequency were obtain- eosinophil count of >500 cells.mm-3; respiratory disease ed at baseline and 1, 2, 3, 4, 5, 6, 8 and 12 h after inhalation. other than COPD; any clinically significant concurrent Twelve-week treatment. Diary card. During the run-in and disease; and oxygen therapy. treatment periods, all patients completed a daily diary card, recording their morning and evening peak expiratory flow (PEF), daytime and night-time symptoms and use of rescue Study design salbutamol. PEF was measured using a Personal Best peak flow meter (Healthscan Products Inc., Cedar Grove, NJ, The study had a randomized, double-blind double-pla- USA) between 07:00 and 08:00 h before taking the study cebo, parallel group design and was performed at three medication and between 19:00 and 20:00 h. The best of centres in the Netherlands. The study was approved by the three measurements was retained. The use of rescue medi- Medical Ethics Committees of all the participating hospi- cation within 4 h of the measurements was also recorded. tals. Written informed consent was obtained from all pa- The following symptom scores were used. Daytime symp- tients before any study procedure was undertaken. The tom score: 0: no symptoms at rest or on exertion; 1: no study had a run-in period of 2 weeks, a treatment period of symptoms at rest but symptoms on moderate exertion, e.g. 12 weeks and a follow-up period of 2 weeks. There were walking quickly, climbing stairs, rushing out to work; 2: no six scheduled visits to the clinic: at the start of the run-in symptoms at rest but symptoms on mild exertion, e.g. get- period (visit 1), at the start of treatment (visit 2), after 4, 8 ting dressed or washed; 3: minimal symptoms at rest, e.g. while sitting reading or watching the television; 4: moder- and 12 weeks of treatment (visits 3±5) and 2 weeks after ate symptoms at rest, e.g. while sitting reading or watching stopping treatment (visit 6) for follow-up. At the start of the the television; and 5: severe symptoms at rest, i.e. patient run-in period, all b -agonists and anticholinergics were 2 unable to carry out any activity requiring exertion. This withdrawn. The patients continued to take the permitted daytime symptom score has been used previously in COPD medication for their COPD in stable doses, including meth- [7]. Night-time symptom score: 0: no symptoms during ylxanthines, oral steroids and inhaled steroids up to 2,000 . -1 . -1 the night; 1: symptoms causing patient to wake once or mg day and fluticasone propionate up to 1,000 mg day . wake early; 2: symptoms causing patient to wake twice or Patients were given salbutamol as rescue medication. At the more (including waking early); 3: symptoms causing end of the run-in period (visit 2), patients were eligible for patient to be awake most of the night; and 4: symptoms so randomization if they fulfilled the following inclusion cri- severe that patient did not sleep at all. This five-point teria: 1) an FEV1 of #65% pred and $0.75 L at visit 1 or 2, symptom score for night-time use has also been used bronchodilators having been withheld for an appropriate previously [9, 13].