William Feldman, MD: Azithromycin Over Roflumilast in Real World COPD Data

Key Takeaways

Propensity-score matching across extensive covariates enabled a head-to-head comparative effectiveness assessment of two exacerbation-prevention therapies previously lacking direct comparisons.
Azithromycin initiation correlated with reduced moderate/severe COPD exacerbations versus roflumilast in the primary matched cohort of 7550 pairs.
Restricting to RELIANCE-like eligibility still showed benefit for azithromycin on hospitalization or death (HR 0.83; 95% CI, 0.72–0.95; NNT 15).
Prespecified subgroup analyses, including prior hospitalization and eosinophil strata, demonstrated broadly consistent effects, informing positioning amid expanding biologic options for eosinophilic COPD.
Clinical application should weigh unmeasured safety tradeoffs (QT/hearing effects vs GI toxicity) and short real-world persistence, pending confirmation from the randomized RELIANCE trial.