Health outcomes following treatment for six months with once daily tiotropium compared with twice daily salmeterol in patients with COPD

Background: A study was undertaken to record exacerbations and health resource use in patients with COPD during 6 months of treatment with tiotropium, salmeterol, or matching placebos. Methods: Patients with COPD were enrolled in two 6-month randomised, placebo controlled, double blind, double dummy studies of tiotropium 18 mug once daily via HandiHaler or salmeterol 50 mug twice daily via a metered dose inhaler. The two trials were combined for analysis of heath outcomes consisting of exacerbations, health resource use, dyspnoea ( assessed by the transitional dyspnoea index, TDI), health related quality of life ( assessed by St George's Respiratory Questionnaire, SGRQ), and spirometry. Results: 1207 patients participated in the study ( tiotropium 402, salmeterol 405, placebo 400). Compared with placebo, tiotropium but not salmeterol was associated with a significant delay in the time to onset of the first exacerbation. Fewer COPD exacerbations/patient year occurred in the tiotropium group (1.07) than in the placebo group (1.49, p< 0.05); the salmeterol group (1.23 events/year) did not differ from placebo. The tiotropium group had 0.10 hospital admissions per patient year for COPD exacerbations compared with 0.17 for salmeterol and 0.15 for placebo ( not statistically different). For all causes ( respiratory and non-respiratory) tiotropium, but not salmeterol, was associated with fewer hospital admissions while both groups had fewer days in hospital than the placebo group. The number of days during which patients were unable to perform their usual daily activities was lowest in the tiotropium group ( tiotropium 8.3 (0.8), salmeterol 11.1 ( 0.8), placebo 10.9 ( 0.8), p< 0.05). SGRQ total score improved by 4.2 (0.7), 2.8 ( 0.7) and 1.5 ( 0.7) units during the 6 month trial for the tiotropium, salmeterol and placebo groups, respectively ( p< 0.01 tiotropium v placebo). Compared with placebo, TDI focal score improved in both the tiotropium group (1.1 (0.3) units, p< 0.001) and the salmeterol group ( 0.7 ( 0.3) units, p< 0.05). Evaluation of morning pre-dose FEV1, peak FEV1 and mean FEV1 (0-3 hours) showed that tiotropium was superior to salmeterol while both active drugs were more effective than placebo. Conclusions: Exacerbations of COPD and health resource usage were positively affected by daily treatment with tiotropium. With the exception of the number of hospital days associated with all causes, salmeterol twice daily resulted in no significant changes compared with placebo. Tiotropium also improved health related quality of life, dyspnoea, and lung function in patients with COPD.