{"id":175203,"date":"2024-03-14T00:00:00","date_gmt":"2024-03-13T23:00:00","guid":{"rendered":"https:\/\/www.bcfi.be\/preferer-les-associations-laba-lama-aux-associations-csi-laba-dans-la-bpco\/"},"modified":"2026-04-02T19:09:07","modified_gmt":"2026-04-02T17:09:07","slug":"preferer-les-associations-laba-lama-aux-associations-csi-laba-dans-la-bpco","status":"publish","type":"post","link":"https:\/\/h.cbip.be\/fr\/preferer-les-associations-laba-lama-aux-associations-csi-laba-dans-la-bpco\/","title":{"rendered":"Pr\u00e9f\u00e9rer les associations LABA + LAMA aux associations CSI + LABA dans la BPCO ?"},"content":{"rendered":"<div class='summary'>Dans la BPCO&#x002C; les donn&eacute;es actuelles ne permettent toujours <b>pas<\/b> de faire un <b>choix clair entre les bith&eacute;rapies LABA + LAMA ou CSI + LABA<\/b>.<br \/> Bien que GOLD 2024 n&rsquo;accorde plus de place aux associations CSI + LABA&#x002C; une <i>Cochrane Review<\/i> et une &eacute;tude de cohorte publi&eacute;e dans le <i>JAMA<\/i> obtiennent des r&eacute;sultats non concordants qui ne permettent <b>pas de conclure &agrave; une efficacit&eacute; sup&eacute;rieure<\/b> <b>des<\/b> associations <b>LABA + LAMA<\/b> sur les sympt&ocirc;mes ou la r&eacute;duction des exacerbations.Les associations <b>CSI + LABA<\/b> entra&icirc;nent par contre <b>plus de pneumonies<\/b>&#x002C; sans mortalit&eacute; suppl&eacute;mentaire.<\/div>\n<h2>Introduction<\/h2>\n<p>Dans la bronchopneumopathie chronique obstructive (BPCO)&#x002C; le traitement m&eacute;dicamenteux comprend l&rsquo;utilisation de&nbsp;:<\/p>\n<ul>\n<li>\n<p>Bronchodilatateurs<\/p>\n<ul>\n<li>\n<p>&beta;<sub>2<\/sub>-mim&eacute;tiques (SABA&nbsp;: short-acting beta-agonists et LABA&nbsp;: long-acting beta agonists)<\/p>\n<\/li>\n<li>\n<p>Anticholinergiques (SAMA&nbsp;: short-acting muscarinic antagonists&nbsp;et LAMA&nbsp;: long-acting muscarinic antagonists)<\/p>\n<\/li>\n<\/ul>\n<\/li>\n<li>\n<p>Corticost&eacute;ro&iuml;des inhal&eacute;s (CSI)<\/p>\n<\/li>\n<\/ul>\n<p>Selon les guidelines<span class='folia-referentie-nummer'><sup>1-4<\/sup><\/span>&#x002C; la premi&egrave;re &eacute;tape du traitement est un bronchodilatateur.<br \/> Quand un bronchodilatateur n&rsquo;est pas suffisant pour contr&ocirc;ler les sympt&ocirc;mes et\/ou en cas d&rsquo;exacerbations&#x002C; quelle est la strat&eacute;gie &agrave; adopter? L&rsquo;ajout d&rsquo;un autre bronchodilatateur (bith&eacute;rapie LABA + LAMA) ou d&rsquo;un CSI&nbsp;(bith&eacute;rapie CSI + LABA) ?<\/p>\n<p>Dans cet article&#x002C; nous pr&eacute;sentons les r&eacute;sultats de deux publications de 2023&nbsp;comparant les deux bith&eacute;rapies : une <em>Cochrane Review<span class='folia-referentie-nummer'><sup>5<\/sup><\/span><\/em> qui est un update d&rsquo;une <em>Cochrane Review<\/em> discut&eacute;e dans le <a href='https:\/\/www.cbip.be\/fr\/articles\/2919?folia=2918'>Folia de 2018 sur le traitement de la BPCO stable<\/a><a>&#x002C;<\/a>&nbsp;et une &eacute;tude de cohorte parue dans le <em>JAMA<span class='folia-referentie-nummer'><sup>6<\/sup><\/span><\/em>.<br \/> &nbsp;<\/p>\n<h2><i>Cochrane Review <\/i><\/h2>\n<h3>Protocole<\/h3>\n<p>Dans l&rsquo;update 2023&#x002C; 8 &eacute;tudes ont &eacute;t&eacute; ajout&eacute;es (total 19 &eacute;tudes&#x002C; 2 &eacute;tudes non-sponsoris&eacute;es). La plupart des &eacute;tudes sont des RCT en double aveugle&#x002C; sauf 2 en open-label. 22 354 patients avec une BPCO stable ont &eacute;t&eacute; inclus. Les participants &eacute;taient majoritairement masculins (70%)&#x002C; &acirc;ge moyen 64 ans et VEMS (volume expiratoire maximal seconde) &agrave; 51% de la valeur pr&eacute;dite. 13 &eacute;tudes ont inclus des patients avec une BPCO mod&eacute;r&eacute;e &agrave; s&eacute;v&egrave;re&#x002C; sans exacerbation r&eacute;cente. 4 &eacute;tudes ont inclus uniquement des patients ayant pr&eacute;sent&eacute; r&eacute;cemment une exacerbation&#x002C; ce qui repr&eacute;sente 65% du total des participants.<br \/> Une bith&eacute;rapie LABA + LAMA ou CSI + LABA a &eacute;t&eacute; &eacute;valu&eacute;e pendant des p&eacute;riodes variant de 6 &agrave; 52 semaines.<\/p>\n<h3>R&eacute;sultats<\/h3>\n<p>Contrairement &agrave; la Cochrane de 2017&#x002C; l&rsquo;update de 2023 n&rsquo;a pas mis en &eacute;vidence de b&eacute;n&eacute;fice des associations LABA + LAMA sur les exacerbations ou la qualit&eacute; de vie par rapport aux CSI + LABA.<\/p>\n<p>En 2023&#x002C; les r&eacute;sultats sont les suivants&nbsp;:<\/p>\n<ul>\n<li>\n<p>Sur les <b>crit&egrave;res d&rsquo;&eacute;valuation primaires<\/b> <b>exacerbations&#x002C; qualit&eacute; de vie et effets ind&eacute;sirables s&eacute;v&egrave;res<\/b>&#x002C; les r&eacute;sultats n&rsquo;ont <b>pas<\/b> montr&eacute; <b>de diff&eacute;rence<\/b> entre les deux bith&eacute;rapies. Le <b>VEMS<\/b> a &eacute;t&eacute; plus <b>am&eacute;lior&eacute; sous LABA + LAMA<\/b> que sous CSI + LABA.<\/p>\n<div class='detailed-content'>\n<ul>\n<li>&ge; 1 exacerbation&nbsp;: OR 0&#x002C;91&#x002C; 95% CI 0&#x002C;78 &agrave; 1&#x002C;06&#x002C; degr&eacute; de certitude mod&eacute;r&eacute; (h&eacute;t&eacute;rog&eacute;n&eacute;it&eacute;)<\/li>\n<li>Qualit&eacute; de vie&nbsp;(score SGRQ) : MD -0&#x002C;57&#x002C; 95% CI -1&#x002C;36 &agrave; 0&#x002C;21&#x002C; degr&eacute; de certitude mod&eacute;r&eacute; (h&eacute;t&eacute;rog&eacute;n&eacute;it&eacute;)<\/li>\n<li>Effets ind&eacute;sirables s&eacute;v&egrave;res&nbsp;: OR 1&#x002C;02&#x002C; 95% CI 0&#x002C;91 &agrave; 1&#x002C;15&#x002C; degr&eacute; de certitude &eacute;lev&eacute;<\/li>\n<li>VEMS&nbsp;: MD 0&#x002C;07&#x002C; 95% CI 0&#x002C;05 &agrave; 0&#x002C;08 degr&eacute; de certitude mod&eacute;r&eacute; (h&eacute;t&eacute;rog&eacute;n&eacute;it&eacute;).<\/li>\n<\/ul><\/div>\n<\/li>\n<li>\n<p>Les autres r&eacute;sultats sont des <b>crit&egrave;res d&rsquo;&eacute;valuation secondaires<\/b>. Il n&rsquo;y a <b>pas<\/b> eu <b>de diff&eacute;rence<\/b> au niveau <b>d&rsquo;une am&eacute;lioration cliniquement pertinente de la qualit&eacute; de vie <\/b>(d&eacute;finie par une diff&eacute;rence de &ge;4 points du score SGRQ).<\/p>\n<\/li>\n<li>\n<p>Les patients sous <b>CSI + LABA<\/b> ont pr&eacute;sent&eacute; <b>plus de pneumonies<\/b> (5% versus 3% sous LABA+LAMA&#x002C; NNH=50). Par contre la <b>mortalit&eacute; toutes causes<\/b> a &eacute;t&eacute; l&eacute;g&egrave;rement <b>plus &eacute;lev&eacute;e sous LABA + LAMA<\/b> (1&#x002C;4% versus 1% sous CSI + LABA&#x002C; NNH=250).<\/p>\n<div class='detailed-content'>\n<ul>\n<li>Pneumonies&nbsp;: 5% sous CSI + LABA versus 3% sous LABA + LAMA. OR 0&#x002C;61&#x002C; 95% CI 0&#x002C;52 &agrave; 0&#x002C;72&#x002C;&nbsp; degr&eacute; de certitude &eacute;lev&eacute;<\/li>\n<li>Mortalit&eacute; toutes causes&nbsp;: 1% sous CSI + LABA versus 1&#x002C;4% sous LABA + LAMA. OR 1&#x002C;35&#x002C; 95% CI 1&#x002C;05 &agrave; 1&#x002C;75&#x002C; degr&eacute; de certitude mod&eacute;r&eacute; (faible nombre d&rsquo;&eacute;v&eacute;nements)<\/li>\n<li>Am&eacute;lioration cliniquement pertinente de la qualit&eacute; de vie (diff&eacute;rence score SGRQ &ge;4 points)&nbsp;: OR 1&#x002C;06&#x002C; 95% CI 0&#x002C;90 &agrave; 1&#x002C;25&#x002C; degr&eacute; de certitude mod&eacute;r&eacute;.<\/li>\n<\/ul><\/div>\n<\/li>\n<\/ul>\n<h3>Limites<\/h3>\n<ul>\n<li>\n<p>Selon les auteurs de la <i>Cochrane Review<\/i> &#x002C; le degr&eacute; de confiance en ces r&eacute;sultats est de mod&eacute;r&eacute; &agrave; &eacute;lev&eacute;. Le risque de biais est g&eacute;n&eacute;ralement faible&#x002C; sauf concernant les conflits d&rsquo;int&eacute;r&ecirc;t (17 &eacute;tudes sur 19 sont sponsoris&eacute;es).<\/p>\n<\/li>\n<li>\n<p>Il n&rsquo;a pas &eacute;t&eacute; possible de faire les analyses de sous-groupes pr&eacute;-sp&eacute;cifi&eacute;es en fonction du degr&eacute; de s&eacute;v&eacute;rit&eacute; de la BPCO par manque de donn&eacute;es sur les participants dans les diff&eacute;rentes &eacute;tudes.<\/p>\n<\/li>\n<li>\n<p>Aucune &eacute;tude n&rsquo;a &eacute;valu&eacute; le risque d&rsquo;hospitalisation li&eacute;e &agrave; une exacerbation.<\/p>\n<\/li>\n<li>\n<p>Les &eacute;tudes &eacute;taient variables concernant l&rsquo;exclusion de personnes souffrant d&rsquo;asthme ou avec une &eacute;osinophilie sanguine. Sachant que ces cat&eacute;gories sont plus susceptibles de b&eacute;n&eacute;ficier d&rsquo;un traitement par CSI&#x002C; les r&eacute;sultats peuvent avoir &eacute;t&eacute; influenc&eacute;s en faveur des CSI.<\/p>\n<\/li>\n<li>\n<p>Concernant la mortalit&eacute; plus &eacute;lev&eacute;e sous LABA + LAMA&#x002C; les auteurs pr&eacute;cisent que le nombre d&rsquo;&eacute;v&eacute;nements &eacute;tait faible. Il s&rsquo;agit d&rsquo;un crit&egrave;re d&rsquo;&eacute;valuation secondaire qui m&eacute;riterait de faire l&rsquo;objet d&rsquo;autres &eacute;tudes. A notre connaissance&#x002C; c&rsquo;est la seule &eacute;tude qui a montr&eacute; une augmentation de la mortalit&eacute; sous LABA + LAMA versus CSI + LABA.<span class='folia-referentie-nummer'><sup>5 <\/sup><\/span><\/p>\n<\/li>\n<\/ul>\n<h2>Etude de cohorte (<i>JAMA<\/i>)<\/h2>\n<h3>Protocole<\/h3>\n<p>L&rsquo;&eacute;tude publi&eacute;e dans le <em>JAMA<\/em> est une &eacute;tude de cohorte &laquo;&nbsp;<a href='https:\/\/www.minerva-ebp.be\/Results\/Glossary\/1819'>propensity score matched&nbsp;<\/a><a>&raquo;<\/a>&nbsp; bas&eacute;e sur les donn&eacute;es d&rsquo;une compagnie d&rsquo;assurance am&eacute;ricaine. 137 833 patients avec un diagnostic de BPCO ont &eacute;t&eacute; inclus (&acirc;ge moyen 70 ans&#x002C; minimum 40 ans pour l&rsquo;inclusion&#x002C; 50&#x002C;4% de femmes). Les patients avec un diagnostic d&rsquo;asthme ou ayant re&ccedil;u une trith&eacute;rapie CSI + LABA + LAMA ont &eacute;t&eacute; exclus. Ils &eacute;taient enregistr&eacute;s depuis au moins un an dans la base de donn&eacute;es&#x002C; et ont &eacute;t&eacute; inclus dans l&rsquo;&eacute;tude &agrave; partir d&rsquo;une premi&egrave;re prescription de LABA + LAMA ou de CSI + LABA. 30 216 paires de patients ont &eacute;t&eacute; utilis&eacute;es pour l&rsquo;analyse.<br \/> De nombreux facteurs confondants ont &eacute;t&eacute; pris en compte.<\/p>\n<h3>R&eacute;sultats<\/h3>\n<p>Deux crit&egrave;res primaires ont &eacute;t&eacute; utilis&eacute;s dans cette &eacute;tude.<\/p>\n<ul>\n<li>\n<p>Le premier est la survenue d&rsquo;une <b>premi&egrave;re exacerbation mod&eacute;r&eacute;e &agrave; s&eacute;v&egrave;re<\/b>. Une exacerbation mod&eacute;r&eacute;e est d&eacute;finie dans l&rsquo;&eacute;tude comme une exacerbation n&eacute;cessitant l&rsquo;utilisation de corticost&eacute;ro&iuml;des oraux pendant 5 &agrave; 14 jours. Une exacerbation s&eacute;v&egrave;re est d&eacute;finie comme une exacerbation n&eacute;cessitant une hospitalisation.<\/p>\n<\/li>\n<li>\n<p>Le second crit&egrave;re primaire est la survenue d&rsquo;une <b>pneumonie n&eacute;cessitant une hospitalisation<\/b>.<\/p>\n<\/li>\n<\/ul>\n<p>Pour les 2 crit&egrave;res&#x002C; les <b>r&eacute;sultats<\/b> ont &eacute;t&eacute; <b>en faveur des LABA + LAMA par rapport aux CSI + LABA&nbsp;<\/b>: -8% pour les exacerbations mod&eacute;r&eacute;es &agrave; s&eacute;v&egrave;res et -20% pour les hospitalisations pour pneumonie.<br \/> <!--[if supportFields]><span style=\u2019font-size:12.0pt;line-height:150%;font-family:'Calibri'&#x002C;sans-serif; mso-ascii-theme-font:minor-latin;mso-fareast-font-family:Calibri;mso-hansi-theme-font: minor-latin;mso-bidi-theme-font:minor-latin;mso-ansi-language:NL-BE;mso-fareast-language: NL-BE;mso-bidi-language:AR-SA\u2019><span style=\u2019mso-element:field-end\u2019><\/span><\/span><![endif]--><\/p>\n<div class='detailed-content'>\n<ul>\n<li>Exacerbation mod&eacute;r&eacute;e &agrave; s&eacute;v&egrave;re&nbsp;: &#8211; 8%&#x002C; HR 0&#x002C;92&nbsp;; 95% CI&#x002C; 0&#x002C;89 &agrave; 0&#x002C;96. R&eacute;duction absolue de 43 &eacute;v&eacute;nements par 1 000 personnes-ann&eacute;es<!--[if gte mso 9]><xml> <w:data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w:data> <\/xml><![endif]--><!--[if supportFields]><span style=\u2019font-size:12.0pt; line-height:150%;font-family:'Calibri'&#x002C;sans-serif;mso-ascii-theme-font:minor-latin; mso-fareast-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family: 'Times New Roman';mso-ansi-language:NL-BE;mso-fareast-language:NL-BE; mso-bidi-language:AR-SA\u2019><span style=\u2019mso-element:field-end\u2019><\/span><\/span><![endif]--><\/li>\n<li>Hospitalisation pour pneumonie&nbsp;: -20%&#x002C; HR 0&#x002C;80&nbsp;; 95% CI&#x002C; 0&#x002C;75 &agrave; 0&#x002C;86. R&eacute;duction absolue de 21&#x002C;9 &eacute;v&eacute;nements par 1 000 personnes-ann&eacute;es<!--[if gte mso 9]><xml> <w:data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w:data> <\/xml><![endif]--><!--[if supportFields]><span style=\u2019font-size:12.0pt; line-height:150%;font-family:'Calibri'&#x002C;sans-serif;mso-ascii-theme-font:minor-latin; mso-fareast-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family: 'Times New Roman';mso-ansi-language:NL-BE;mso-fareast-language:NL-BE; mso-bidi-language:AR-SA\u2019><span style=\u2019mso-element:field-end\u2019><\/span><\/span><![endif]--><!--[if gte mso 9]><xml> <w:data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w:data> <\/xml><![endif]--><!--[if supportFields]><span style=\u2019font-size:12.0pt; line-height:150%;font-family:'Calibri'&#x002C;sans-serif;mso-ascii-theme-font:minor-latin; mso-fareast-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family: 'Times New Roman';mso-ansi-language:NL-BE;mso-fareast-language:NL-BE; mso-bidi-language:AR-SA\u2019><span style=\u2019mso-element:field-end\u2019><\/span><\/span><![endif]--><!--[if supportFields]><span style=\u2019font-size:12.0pt; line-height:150%;font-family:'Calibri'&#x002C;sans-serif;mso-ascii-theme-font:minor-latin; mso-fareast-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family: 'Times New Roman';mso-ansi-language:NL-BE;mso-fareast-language:NL-BE; mso-bidi-language:AR-SA\u2019><span style=\u2019mso-element:field-end\u2019><\/span><\/span><![endif]--><\/li>\n<\/ul><\/div>\n<p>Les r&eacute;sultats sur le crit&egrave;re des exacerbations n&rsquo;&eacute;taient plus statistiquement significatifs lors d&rsquo;analyses de sous-groupes pr&eacute;-sp&eacute;cifi&eacute;es telles que le stade selon GOLD&#x002C; les ant&eacute;c&eacute;dents d&rsquo;exacerbation ou l&rsquo;&eacute;osinophilie.<\/p>\n<h3>Limites<\/h3>\n<p>Selon les auteurs&#x002C; en plus d&rsquo;&ecirc;tre une &eacute;tude observationnelle&#x002C; cette &eacute;tude pr&eacute;sente plusieurs limites.<\/p>\n<ul>\n<li>\n<p>La dur&eacute;e de suivi &eacute;tait courte&nbsp;: jusqu&rsquo;&agrave; la survenue du crit&egrave;re d&rsquo;&eacute;valuation&#x002C; et maximum un an.<\/p>\n<\/li>\n<li>\n<p>Les analyses ont &eacute;t&eacute; li&eacute;es &agrave; la d&eacute;livrance de prescriptions m&eacute;dicales. Ce qui n&rsquo;implique pas d&rsquo;office que les patients ont pris leur traitement ou l&rsquo;ont pris correctement.<\/p>\n<\/li>\n<li>\n<p>Les patients recevant une association CSI + LABA pr&eacute;sentaient en g&eacute;n&eacute;ral une BPCO plus s&eacute;v&egrave;re&#x002C; et avaient moins acc&egrave;s aux soins que les patients sous LABA + LAMA.&nbsp;<br \/> Cela peut avoir pour cons&eacute;quence la survenue d&rsquo;&eacute;v&eacute;nements plus d&eacute;favorables dans le groupe CSI + LABA. Les auteurs n&rsquo;excluent pas la possibilit&eacute; de facteurs confondants r&eacute;siduels.<span class='folia-referentie-nummer'><sup>6<\/sup><\/span><\/p>\n<\/li>\n<\/ul>\n<h2>Commentaire du CBIP<\/h2>\n<ul>\n<li>\n<p>Il reste difficile de faire un choix entre bith&eacute;rapie LABA + LAMA versus CSI + LABA dans la BPCO.<\/p>\n<\/li>\n<li>\n<p>GOLD 2024 n&rsquo;accorde plus de place aux associations CSI + LABA. Cependant&#x002C; les derni&egrave;res &eacute;tudes analys&eacute;es dans cet article ne montrent pas de mani&egrave;re univoque une sup&eacute;riorit&eacute;&nbsp;des associations LABA + LAMA par rapport aux CSI + LABA en termes de soulagement des sympt&ocirc;mes ou de r&eacute;duction du nombre d&rsquo;exacerbations.<\/p>\n<\/li>\n<li>\n<p>Ces &eacute;tudes confirment par contre le risque plus &eacute;lev&eacute;&nbsp;de pneumonies sous CSI + LABA&#x002C; mais ce risque ne semble pas entra&icirc;ner de d&eacute;c&egrave;s suppl&eacute;mentaires.<\/p>\n<\/li>\n<li>\n<p>La <i>Cochrane Review<\/i> mentionne pour la premi&egrave;re fois une mortalit&eacute; toutes causes plus &eacute;lev&eacute;e sous LABA + LAMA. Les causes de d&eacute;c&egrave;s ne sont pas rapport&eacute;es. Ces r&eacute;sultats sont &agrave; prendre avec pr&eacute;cautions&#x002C; vu le faible nombre d&rsquo;&eacute;v&eacute;nements. Puisqu&rsquo;il s&rsquo;agit de mortalit&eacute; globale&#x002C; il serait int&eacute;ressant de disposer d&rsquo;&eacute;tudes suppl&eacute;mentaire &agrave; ce sujet.<\/p>\n<\/li>\n<\/ul>\n<h3>Liste des associations fixes LABA + LAMA et CSI + LABA ayant la BPCO comme indication dans le RCP<\/h3>\n<p><strong>LABA + LAMA<\/strong><\/p>\n<p><a href='https:\/\/www.cbip.be\/fr\/chapters\/5?frag=20594'>Voir aussi R&eacute;pertoire<\/a><\/p>\n<ul>\n<li>\n<p>Aclidinium + formot&eacute;rol&nbsp;: Duaklir&reg;<\/p>\n<\/li>\n<li>\n<p>Glycopyrronium + indacat&eacute;rol&nbsp;: Ultibro&reg;<\/p>\n<\/li>\n<li>\n<p>Tiotropium + olodat&eacute;rol&nbsp;: Spiolto&reg;&#x002C; Yanimo&reg;<\/p>\n<\/li>\n<li>\n<p>Um&eacute;clidinium + vilant&eacute;rol&nbsp;: Anoro&reg;<\/p>\n<\/li>\n<\/ul>\n<p><strong>CSI&nbsp;+ LABA<\/strong><\/p>\n<p><a href='https:\/\/www.cbip.be\/fr\/chapters\/5?frag=3780'>Voir aussi R&eacute;pertoire<\/a><\/p>\n<ul>\n<li>\n<p>Formot&eacute;rol + bud&eacute;sonide&nbsp;: Symbicort&reg;&#x002C; Airbufo&reg;&#x002C; Bufomix&reg;<\/p>\n<\/li>\n<li>\n<p>Formot&eacute;rol + b&eacute;clom&eacute;tasone&nbsp;: Inuvair&reg;<\/p>\n<\/li>\n<li>\n<p>Salm&eacute;t&eacute;rol + fluticasone&nbsp;: Seretide Diskus&reg;&#x002C; Airflusal&reg;&#x002C; Flutisamix&reg;<\/p>\n<\/li>\n<li>\n<p>Vilant&eacute;rol + fluticasone&nbsp;: Relvar&reg;<\/p>\n<\/li>\n<\/ul>\n<h2> Sources<\/h2>\n<p><span class='folia-referentie-tekst'><span class='folia-referentie-nummer'>1&nbsp;<\/span><a href='https:\/\/goldcopd.org\/2024-gold-report\/'>https:\/\/goldcopd.org\/2024-gold-report\/<\/a><\/span><br \/> <span class='folia-referentie-tekst'><span class='folia-referentie-nummer'>2&nbsp;<\/span><a href='https:\/\/bestpractice.bmj.com\/topics\/en-gb\/7\/treatment-algorithm'>https:\/\/bestpractice.bmj.com\/topics\/en-gb\/7\/treatment-algorithm<\/a><\/span><br \/> <span class='folia-referentie-tekst'><span class='folia-referentie-nummer'>3<\/span><\/span>&nbsp;<span class='folia-referentie-tekst'><a href='https:\/\/richtlijnen.nhg.org\/standaarden\/copd#volledige-tekst-medicamenteuze-behandeling-copd'>https:\/\/richtlijnen.nhg.org\/standaarden\/copd#volledige-tekst-medicamenteuze-behandeling-copd<\/a><\/span><br \/> <span class='folia-referentie-tekst'><span class='folia-referentie-nummer'>4<\/span><\/span>&nbsp;<span class='folia-referentie-tekst'><a href='https:\/\/www.nice.org.uk\/guidance\/ng115\/chapter\/Recommendations#managing-stable-copd'>https:\/\/www.nice.org.uk\/guidance\/ng115\/chapter\/Recommendations#managing-stable-copd<\/a><\/span><br \/> <span class='folia-referentie-tekst'><span class='folia-referentie-nummer'>5<\/span><\/span>&nbsp;<span class='folia-referentie-tekst'>Fukuda N&#x002C; Horita N&#x002C; Kaneko A&#x002C; Goto A&#x002C; Kaneko T&#x002C; Ota E&#x002C; Kew KM. Long\u2010acting muscarinic antagonist (LAMA) plus long\u2010acting beta\u2010agonist (LABA) versus LABA plus inhaled corticosteroid (ICS) for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2023&#x002C; Issue 6. Art. No.: CD012066. DOI: 10.1002\/14651858.CD012066.pub3. Accessed 19 January 2024.<\/span><br \/> <span class='folia-referentie-tekst'><span class='folia-referentie-nummer'>6<\/span>&nbsp;Feldman WB&#x002C;&nbsp;Avorn J&#x002C;&nbsp;Kesselheim AS&#x002C;&nbsp;Gagne JJ. Chronic Obstructive Pulmonary Disease Exacerbations and Pneumonia Hospitalizations Among New Users of Combination Maintenance Inhalers.&nbsp;<em>JAMA Intern Med.<\/em>&nbsp;2023;183(7):685&ndash;695. doi:10.1001\/jamainternmed.2023.1245<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Dans la BPCO&#x002C; les donn&eacute;es actuelles ne permettent toujours pas  [&#8230;]<\/p>\n","protected":false},"author":9,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[12,20295],"tags":[20213,20224],"class_list":["post-175203","post","type-post","status-publish","format-standard","hentry","category-actualites","category-2024-fr","tag-import_tags","tag-import_tags-nl"],"_links":{"self":[{"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/posts\/175203","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/comments?post=175203"}],"version-history":[{"count":2,"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/posts\/175203\/revisions"}],"predecessor-version":[{"id":180268,"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/posts\/175203\/revisions\/180268"}],"wp:attachment":[{"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/media?parent=175203"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/categories?post=175203"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/h.cbip.be\/fr\/wp-json\/wp\/v2\/tags?post=175203"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}