Salmeterol and Fluticasone Propionate and Survival in COPD (TORCH)

ICS/LABA combinations were widely used in COPD but their effect on mortality was unknown. TORCH was the first large trial powered for mortality in COPD.

Multicenter RCT (n=6,112) comparing salmeterol/fluticasone (SFC) vs. salmeterol alone, fluticasone alone, or placebo over 3 years in COPD patients (FEV1 <60%).

SFC reduced all-cause mortality by 17.5% vs placebo (p=0.052 — missed statistical significance). SFC significantly reduced exacerbations (25% reduction) and improved health status. ICS use increased pneumonia risk (19.6% vs 12.3%).

ICS/LABA combination reduces COPD exacerbations and improves quality of life but increases pneumonia risk. ICS should not be used as monotherapy in COPD. Per GOLD 2024, ICS/LABA is appropriate for patients with frequent exacerbations or eosinophils ≥300.

Missed primary mortality endpoint (p=0.052). Pneumonia risk with ICS is a real clinical concern. Patients with asthma-COPD overlap may have been included.