title: Pharmacotherapies for chronic obstructive pulmonary disease: a multiple treatment comparison meta-analysis.
abstract: BACKGROUND
  Most patients with moderate and severe chronic obstructive pulmonary disease (COPD) receive long-acting bronchodilators (LABA) for symptom control. It is, however, unclear if and what drug treatments should be added to LABAs to reduce exacerbations, which is an important goal of COPD management. Since current guidelines cannot make strong recommendations yet, our aim was to determine the relative efficacy of existing treatments and combinations to reduce the risk for COPD exacerbations.
  
  
  METHODS
  We included randomized clinical trials (RCTs) evaluating long-acting β(2) agonists (LABA), long-acting muscarinic antagonists (LAMA), inhaled glucocorticosterioids (ICS), and the phosphodiesterase-4 (PDE4) inhibitor roflumilast, and combinations of these interventions in moderate to severe COPD populations. Our primary outcome was the event rate of exacerbations. We conducted a random-effects Bayesian mixed-treatment comparison (MTC) and applied several sensitivity analyses. In particular, we confirmed our findings using a binomial MTC analysis examining whether a patient experienced at least one exacerbation event or not during the trial. We also used an additive assumption to calculate the combined effects of treatments that were not included in the systematic review.
  
  
  RESULTS
  Twenty-six studies provided data on the total number of exacerbations and/or the mean annual rate of exacerbations among a combined 36,312 patients. There were a total of 10 treatment combinations in the MTC and 15 in the additive analysis. Compared with all other treatments, the combination of roflumilast plus LAMA exhibited the largest treatment effects, and had the highest probability (45%) of being the best first-line treatment. This was consistent whether applying the incidence rate analysis or the binomial analysis. When applying the additive assumption, most point estimates suggested that roflumilast may provide additional benefit by further reducing exacerbations.
  
  
  CONCLUSIONS
  Using various meta-analytic approaches, our study demonstrates that depending on the choice of drug, combined treatments offer a therapeutic advantage.
authors.affiliation: Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada;
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
authors.forename: Eric
authors.initials: E
authors.lastname: Druyts
authors.forename: Isabella
authors.initials: I
authors.lastname: Ghement
authors.forename: Milo A
authors.initials: MA
authors.lastname: Puhan