Ipratropium as an adjunct to beta2 agonists for acute asthma
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02.09.2017 • Sonuncu dəyişiklik 02.09.2017
Editors
Combination inhaled therapy with short-acting anticholinergics and short-acting beta-agonists are effective for acute asthma in adults compared with beta-agonist alone.
A Cochrane review included 23 studies with a total of 2 724 adult participants. Patients receiving combination inhaled therapy with short-acting anticholinergics (SAAC) and short-acting beta-agonists (SABA) were less likely to be hospitalised, were more likely to experience improved forced expiratory volume (FEV1) and peak expiratory flow (PEF), and were less likely to return to the emergency department for additional care than participants receiving SABA alone (table ). In particular, combination inhaled therapy was more effective in preventing hospitalisation in adults with severe asthma exacerbations who are at increased risk of hospitalisation, compared to those with mild-moderate exacerbations. Adverse events, such as tremor, agitation, and palpitations, were more common with combination therapy compared to SABA alone (table ).
Combination inhaled therapy compared with SABA alone for acute asthma
| Outcome | Relative effect
(95% CI) | Assumed risk with control - SABA alone | Risk difference with intervention - SABA + SAAC (95% CI) | No of Participants
(studies) Quality of evidence |
| Hospitalisation | RR 0.72 (0.59 to 0.86) | 231 per 1000 | 65 fewer per 1000
(from 30 fewer to 95 fewer) | 2120 (16) Moderate |
| Total adverse events | OR 2.03 (1.28 to 3.20) | 131 per 1000 | 103 more per 1000
(from 31 more to 195 more) | 1392
(11) Moderate |
| FEV1 | _ | Range 1.36 to 2.4 Litres | MD 0.25 higher
(0.02 to 0.48 higher) | 687
(6) Low |
| Peak expiratory flow (PEF) | _ | Range 190 to 313 litres/min | MD 36.58 higher
(23.07 to 50.09 higher) | 1056
(12) Moderate |
| Relapse rates | RR 0.8 (0.66 to 0.98) | 250 per 1000 | 50 fewer per 1000
(from 5 fewer to 85 fewer) | 1180
(5) Moderate |
A systematic review including 10 RCTs with a total of 1 377 subjects was abstracted in DARE. Compared to placebo, the use of ipratropium/beta agonist in adults with acute asthma exacerbation was associated with a pooled improvement of FEV1 of 7.3% (95% CI 3.8% to 10.9%), corresponding to an absolute improvement of 100 ml above that seen for the group receiving only beta agonist, and with a pooled improvement of PEFR of 22.1% (95% CI 11.0% to 33.2%) corresponding to an absolute improvement of 32 l/min (95% CI 16 to 47 l/min) above that seen for the group receiving only beta agonist. Studies enrolling patients with more severe airway obstruction at baseline appeared to show greater absolute improvement with ipratropium bromide.
Another systematic review including 10 studies with a total of 1 483 subjects was abstracted in DARE. The addition of ipratropium to beta agonist therapy led to a significant benefit in fulmonary function at 90 minutes (pooled effect size 0.14, 95% CI 0.04 to 0.24) and to a significant reduction in the hospital admission rates (OR 0.62, 95% CI 0.44 to 0.88; NNT 18, 95% CI 11 to 77; 5 RCTs, n=1 186). For the 4 studies of patients with FEV1 or PEF less than 35% of the predicted value, the addition of ipratropium to beta-agonist therapy led to a significant benefit (pooled effect size 0.38, 95% CI 0.09 to 0.67). Systemic steroids had a moderate effect on outcome (pooled effect size 0.14, 95% CI 0.00 to 0.28). Concerning adverse effects, there were no significant differences between the treatment groups in terms of tremor, heart rate, blood-pressure, respiratory rate, anxiety, dry mouth, or oxygen saturation.
Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding in most of the studies).
Ədəbiyyat
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Stoodley RG, Aaron SD, Dales RE. The role of ipratropium bromide in the emergency management of acute asthma exacerbation: a metaanalysis of randomized clinical trials. Ann Emerg Med 1999 Jul;34(1):8-18.
Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Am J Med 1999 Oct;107(4):363-70.
- Kirkland SW, Vandenberghe C, Voaklander B et al. Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma. Cochrane Database Syst Rev 2017;(1):CD001284.