We identified seven randomised trials (5997 participants) of good quality with a duration of six months to three years. All of the trials compared ICS/LABA combination inhalers with LABA and ICS as individual components. Four of these trials included fluticasone and salmeterol monocomponents and the remaining three included budesonide and formoterol monocomponents. There was no statistically significant difference in our primary outcome , the number of patients experiencing exacerbations ( odds ratio ( OR ) ; 95% CI to ), or the rate of exacerbations per patient year (rate ratio ( RR ) ; 95% CI to ) between inhaled corticosteroids and long-acting beta 2 -agonists. The incidence of pneumonia, our co-primary outcome , was significantly higher among patients on inhaled corticosteroids than on long-acting beta 2 -agonists whether classified as an adverse event ( OR ; 95% CI to ) or serious adverse event (Peto OR ; 95% CI to ). Results of the secondary outcomes analysis were as follows. Mortality was higher in patients on inhaled corticosteroids compared to patients on long-acting beta 2 -agonists (Peto OR ; 95% CI to ), although the difference was not statistically significant . Patients treated with beta 2 -agonists showed greater improvements in pre-bronchodilator FEV 1 compared to those treated with inhaled corticosteroids ( mean difference ( MD ) mL; 95% CI to ), whilst greater improvements in health-related quality of life were observed in patients receiving inhaled corticosteroids compared to those receiving long-acting beta 2 -agonists (St George's Respiratory Questionnaire (SGRQ) MD -; 95% CI - to -). In both cases the differences were statistically significant but rather small in magnitude. There were no statistically significant differences between ICS and LABA in the number of hospitalisations due to exacerbations, number of mild exacerbations, peak expiratory flow, dyspnoea , symptoms scores, use of rescue medication, adverse events, all cause hospitalisations, or withdrawals from studies.
Unfamiliarity with these newer inhalers has been the source of some recently reported errors. A patient discharged from the hospital on Spiriva HandiHaler was readmitted 3 days later after taking 3 Spiriva capsules by mouth each day. He was unaware that the capsule was to be placed in the device so its contents could be inhaled. A color-blind patient was unable to tell if the indicator window on a Tudorza Pressair inhaler was red or green. The window turns green when the inhaler is loaded with a dose and ready to use, and red when the dose has been completely inhaled. Errors have happened to healthcare providers, too. In the pharmacy, an order for Incruse Ellipta was mistaken as “Increase Ellipta,” and the pharmacist dispensed Breo Ellipta, the only “Ellipta” inhaler with which he was familiar.