The National Prescribing Centre (NPC) has published MeReC Extra 28 that provides a summary of the recently published TORCH study, a discussion of when the benefits outweigh the risks using the combination of aspirin and warfarin and an insight to some future NPC work.
The TORCH study was a randomised controlled trial examining the effects of fluticasone, salmeterol and the combination of these two drugs on mortality in patients with chronic obstructive pulmonary disease (COPD). After three years there was no difference in deaths between the combination arm and the placebo arm of the study. There were some differences in secondary end points, for example there were fewer moderate to severe exacerbations and lung function as measured by FEV1.
Interestingly, in comparison to salmeterol alone, the combination did not reduce the number of hospital admissions. Also, it was noted that pneumonia occurred more frequently in the fluticasone and combination arms. The MeReC calculates that for every 17 people treated with the combination for 3 years as opposed to salmeterol alone, 1 will suffer pneumonia!
The key messages for clinicians about this study are:
- It supports the current NICE Guideline for COPD
- Combination therapies appear to reduce exacerbations but not hospital admissions
- There may be a link between pneumonia and inhaled steroids in COPD patients that requires further investigation
This MeReC also discusses when the additional risk of bleeding caused by the combination of aspirin and warfarin is balanced by clinical benefit. This section covers a recent meta-analysis of 10 trials in patients at high risk of thromboembolism, for example those with mechanical heart valves and atrial fibrillation. The majority of patients in whom the combination might be beneficial will be seen in secondary care. This combination should not be routinely initiated in the primary care setting.
Finally, the article reveals a little more information about NPCi and also reveals the next two MeReC Bulletin topics. These will be the role of newer insulins in diabetes and the management of rheumatoid arthritis. More details of these will be posted when the Bulletins are made available.
Action: As always, the NPC have provided a high quality summary of the latest topical issues. Clinicians will find this publication useful and informative.
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