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The FLAME trial addressed a practical COPD question: for patients at risk of exacerbations, is a long-acting beta2-agonist plus long-acting muscarinic antagonist better than an inhaled corticosteroid/LABA combination? In this 52-week randomized trial, once-daily indacaterol–glycopyrronium was compared with salmeterol–fluticasone in more than 3,300 patients with COPD and a history of exacerbation. The dual-bronchodilator regimen was noninferior and showed a lower overall exacerbation rate than the LABA–ICS regimen. Moderate-to-severe exacerbations were also less frequent with indacaterol–glycopyrronium, and pneumonia occurred less often in that group. The clinically useful message is not that ICS has no role in COPD, but that bronchodilation should remain central to maintenance treatment and that routine LABA–ICS is not necessarily the best starting strategy for every patient. In practice, treatment should be individualized around exacerbation history, symptom burden, blood eosinophils, and coexisting asthma features. The study is especially relevant to the conference focus on moving beyond spirometry alone when phenotyping COPD and making the ICS decision.
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The FLAME trial addressed a practical COPD question: for patients at risk of exacerbations, is a long-acting beta2-agonist plus long-acting muscarinic antagonist better than an inhaled corticosteroid/LABA combination? In this 52-week randomized trial, once-daily indacaterol–glycopyrronium was compared with salmeterol–fluticasone in more than 3,300 patients with COPD and a history of exacerbation. The dual-bronchodilator regimen was noninferior and showed a lower overall exacerbation rate than the LABA–ICS regimen. Moderate-to-severe exacerbations were also less frequent with indacaterol–glycopyrronium, and pneumonia occurred less often in that group. The clinically useful message is not that ICS has no role in COPD, but that bronchodilation should remain central to maintenance treatment and that routine LABA–ICS is not necessarily the best starting strategy for every patient. In practice, treatment should be individualized around exacerbation history, symptom burden, blood eosinophils, and coexisting asthma features. The study is especially relevant to the conference focus on moving beyond spirometry alone when phenotyping COPD and making the ICS decision.
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