Anticholinergic agents for chronic asthma in adults

Westby M, Benson M, Gibson P

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Summary

Not enough evidence to justify the routine use of anticholinergic agents such as Atrovent in adults with chronic asthma

Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta-agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 2, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Westby M, Benson M, Gibson P. Anticholinergic agents for chronic asthma in adults. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003269. DOI: 10.1002/14651858.CD003269.pub2

This version first published online: July 19. 2004

Abstract

Background

Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 -agonists in the management of chronic asthma.

Objectives

To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 -agonists or as adjunctive therapy to ß2 -agonists.

Search strategy

The Cochrane Airways Group asthma and wheeze database was searched with a pre-defined search strategy. Searches were current as of August 2004. Reference lists of articles were also examined.

Selection criteria

Randomised trials or quasi-randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 -agonists were included. In practice, all ß2 -agonists were short acting. Short-term (less than 24 hours duration) and longer-term studies were separated; the latter are reported in this review and the former in the review, "Anticholinergic agents for chronic asthma in adults short term".

Data collection and analysis

Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies.

Main results

The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 -agonists versus short acting ß2 -agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies.
Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD -0.09 (95%CI -0.14, -0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo.
The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 -agonist versus short acting ß2 -agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies.

Authors' conclusions

Overall this review provides no justification for routinely introducing anticholinergics as part of add-on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub-group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review.

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