Should Patients Switched from D to B in the GOLD 2017 Classification be Discontinued from Inhaled Corticosteroids?

A descriptive cohort study of withdrawal from inhaled corticosteroids in COPD patients

Inhaled corticosteroid (ICS) therapy is widely prescribed without a history of exacerbations and consensus guidelines suggest withdrawal of ICS in these patients would reduce the risk of side effects and promote cost-effective prescribing. The study describes the prescribing behaviour in the United Kingdom (UK) in relation to ICS withdrawal and identifies clinical outcomes following withdrawal using primary and secondary care electronic health records between January 2012 and December 2017. Patients with a history ≥12 months’ exposure who withdrew ICS for ≥6 months were identified into two cohorts; those prescribed a long-acting bronchodilator maintenance therapy and those that were not prescribed any maintenance therapy. The duration of withdrawal, predictors of restarting ICS, and clinical outcomes were compared between both patient cohorts. Among 76,808 patients that had ≥1 prescription of ICS in the study period, 11,093 patients (14%) withdrew ICS therapy at least once during the study period. The median time without ICS was 9 months (IQR 7–14), with the majority (71%) receiving subsequent ICS prescriptions after withdrawal. Patients receiving maintenance therapy with a COPD review at withdrawal were 28% less likely to restart ICS (HR: 0.72, 95% CI 0.61, 0.85). Overall, 69% and 89% of patients that withdrew ICS had no recorded exacerbation event or COPD hospitalisation, respectively, during the withdrawal. This study provides evidence that most patients withdrawing from ICS do not experience COPD exacerbations and withdrawal success can be achieved by carefully planning routine COPD reviews whilst optimising the use of available maintenance therapies.

Severity distribution and treatment of chronic obstructive pulmonary disease in China: baseline results of an observational study

Background

Chronic obstructive pulmonary disease (COPD) receives low awareness and is undertreated in China. Understanding the burden and treatment of COPD across the nation is important for improving quality of care for this disease. This study aims to reveal the current situation of COPD severity distribution and management across China.

Methods

Baseline data from REALizing and Improving Management of Stable COPD in China, a multicentre, prospective, longitudinal, observational study, were analysed. Patients diagnosed with COPD as per Global Initiative for Chronic Obstructive Lung Disease 2016 (GOLD 2016) criteria were enrolled from 50 randomly selected hospitals (tertiary, 25; secondary, 25) across six geographical regions. Data were collected in routine clinical settings.

Results

Between 15 December 2017 and 6 August 2020, 5013 patients were enrolled and 4978 included in the full analysis set. Of these, 2459 (49.4%) reported ≥ 1 exacerbation within 12 months prior to study enrolment, with a mean annual rate of 0.9/patient, including 0.2/patient and 0.5/patient leading to emergency room visits and hospitalisation, respectively. Spirometry graded 458 (10.1%), 1886 (41.7%), 1558 (34.5%), and 616 (13.6%) were GOLD stage I–IV, and 536 (11.4%), 1034 (22.0%), 563 (12.0%), and 2566 (54.6%) were classified as GOLD 2016 Group A–D, respectively, without evident regional variations. Inhaled corticosteroids plus long-acting beta₂-agonist (ICS/LABA, 1316 [26.4%]), ICS/LABA plus long-acting muscarinic antagonist (ICS/LABA + LAMA, 871 [17.5%]), and LAMA (754 [15.1%]) were prescribed at high rates across all groups and regions. Medications not recommended by GOLD were commonly prescribed (TCM, 578 [11.6%]; others, 951 [19.1%]), and 681 (13.7%) were not given ICS or long-acting bronchodilators.

Conclusions

Disease burden among Chinese COPD outpatients is high. Improved guideline adherence for COPD treatment is needed.

Trial registration ClinicalTrials.gov identifier, NCT03131362.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02021-w.

Adherence to Treatment Recommendations for Chronic Obstructive Pulmonary Disease - Results from the Swedish National Airway Register

Introduction

Swedish guidelines adhere to the international GOLD document regarding management of chronic obstructive pulmonary disease (COPD). Based on data from the Swedish National Airway Register (SNAR) the aim was to evaluate adherence to guidelines of pharmacological treatment of COPD in Swedish primary and secondary care.

Methods

During a period of 18 months, data on symptoms (CAT, mMRC), lung function, exacerbation history and pharmacological treatment from 15,595 COPD patients from 853 primary care and 125 secondary care clinics were collected from SNAR. Patients with a co-diagnosis of asthma were excluded. Patients were divided into four treatment groups: no pharmacological treatment, short-acting bronchodilators alone, long-acting bronchodilators alone and ICS alone or in combination with bronchodilators.

Results

Of the patients, 29% were in GOLD group A, 58% in group B, 2% in group C and 11% in group D. CAT score was ≥10 and mMRC score was below 2 in 30.9% of the patients and mMRC score was ≥2 and CAT score <10 in 4.2% of the patients. In 61.4% of the patients, no exacerbation was registered during the last year. Long-acting bronchodilators were prescribed for 78% and ICS for 46% of all patients. In groups A, B, C and D, respectively, 21%, 11%, 11% and 5% did not receive any inhaler therapy; 67%, 81%, 81% and 90% received long-acting bronchodilators; 33%, 46%, 55% and 71% received any ICS containing therapy and 19%, 34%, 39% and 61% received triple therapy.

Discussion

Data from the SNAR indicate that only a minority of COPD patients were untreated. There was a liberal use of ICS containing drug combinations in subjects who do not have an indication for ICS. A considerable proportion of subjects at high risk of exacerbations did not receive ICS treatment.

A Simplified Algorithm for the Diagnosis, Treatment, and Management of COPD in Routine Primary Care Practice

Background

Diagnostic and treatment strategies for chronic obstructive pulmonary disease (COPD) vary greatly. Despite international efforts to standardize the management of COPD, two-thirds of primary care patients are not diagnosed, treated, or managed according to current evidence-based guidelines, probably because of the difficulty of applying these in routine practice. The aim of this study was to develop a simplified algorithm for diagnosing, treating, and managing COPD in primary care whose consistency, scientific relevance, and applicability to routine clinical practice met approval bct 3y family doctors (FDs) and pulmonologists.

Methods

The algorithm was developed in a series of sequential phases, consisting of a preliminary meeting among group coordinators to design the initial structure, an input meeting with FDs and pulmonologists to refine and validate the proposal, an algorithm design stage, and a Delphi survey in which FDs and pulmonologists evaluated and approved the final version. A target of 75% or more was established for each of the 20 items in the Delphi survey in the FDs group as well as the pulmonologists group. It was estimated that at least two Delphi rounds would be needed to reach consensus.

Results

In total, 118 physicians (75 FDs and 43 pulmonologists) participated in the Delphi process. Fourteen of the 20 items (70%) were approved in the first round. In the second round (in which 74 FDs and 42 pulmonologists participated), the remaining six items, which had been reformulated based on feedback from the first round, were approved, together with an additional question on the face validity of the algorithm as a whole. Dyspnea was positioned as the main determinant of treatment decisions in the new algorithm.

Conclusion

According to the experts consulted, this new simplified algorithm for the diagnosis, treatment, and management of COPD in primary care is a clear, functional, and useful tool for routine practice and meets the requirements for the correct management of this condition.

Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline

Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL^-1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.

A Framework For Step Down Or Therapeutic Re-Organization For Withdrawal Of Inhaled Corticosteroids In Selected Patients With COPD: A Proposal For COPD Management

While chronic obstructive pulmonary disease (COPD) continues to be a major cause of morbidity and mortality, pharmacological therapy has a definite benefit on symptoms as well as the frequency and severity of exacerbations, and general health. The most recent Global Initiative for Obstructive Lung Disease (GOLD) guidelines recommend triple therapy (long-acting beta2 agonists [LABA] + long-acting muscarinic antagonists [LAMA] + inhaled corticosteroids [ICS]) only for patients with exacerbations, elevated eosinophils, and without control using a LABA/LAMA or ICS/LABA combination. Long-term monotherapy with ICS is not currently recommended, but may be considered in association with LABAs in patients with a history of exacerbations and elevated eosinophils in spite of appropriate treatment with long-acting bronchodilators. However, long-term use of ICS in combination therapy has been associated with adverse effects, even if widely used in routine management for decades. The available evidence suggests that ICS can be rationally discontinued in patients with stable disease and is not likely to have unfavorable effects on lung function, overall health, or be associated with a greater risk of exacerbations. Indeed, it is widely accepted that ICS therapy should be limited to a small proportion of patients after careful assessment of the individual risk-benefit profile. Unfortunately, however, there are no international recommendations that provide specific guidance or a protocol for withdrawal of ICS. Herein, the available evidence on the use of ICS is reviewed and an easy to use tool is proposed that can provide clinicians with a simple management scheme to guide the most appropriate therapy for management of COPD and use of ICS. In management of COPD, a highly personalized approach is advocated so that the most appropriate therapy for each individual patient can be selected.

Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms

Observational studies indicate that overutilization of inhaled corticosteroids (ICS) is common in patients with chronic obstructive pulmonary disease (COPD). Overprescription and the high risk of serious ICS-related adverse events make withdrawal of this treatment necessary in patients for whom the treatment-related risks outweigh the expected benefits. Elaboration of an optimal, universal, user-friendly algorithm for withdrawal of ICS therapy has been identified as an important clinical need. This article reviews the available evidence on the efficacy, risks, and indications of ICS in COPD, as well as the benefits of ICS treatment withdrawal in patients for whom its use is not recommended by current guidelines. After discussing proposed approaches to ICS withdrawal published by professional associations and individual authors, we present a new algorithm developed by consensus of an international group of experts in the field of COPD. This relatively simple algorithm is based on consideration and integrated assessment of the most relevant factors (markers) influencing decision-making, such a history of exacerbations, peripheral blood eosinophil count, presence of infection, and risk of community-acquired pneumonia.

New combined assessment of chronic obstructive pulmonary disease: Utilization, pitfalls, and association with spirometry

Introduction

Classification of chronic obstructive pulmonary (COPD) disease has changed from being solely based on spirometric variables to combined assessment including symptom scores and history of exacerbations/ hospitalizations. There is both lack of awareness regarding change in its assessment as well as underutilization due to time constraints and seeming complexity. Moreover, treatment of COPD needs to be tailored according to the new combined assessment.

Aims

Current study was planned to look at current stratification of patients according to new revised combined assessment (Global Initiative for Chronic Obstructive Lung Disease GOLD 2017) in comparison to old(GOLD 2011) as well as its incorporation in clinical practice. Co-relation between revised combined assessment and spirometric staging was also assessed.

Methods

418 consecutive COPD patients were enrolled, their dyspnea scores in terms of modified medical research council scale (mMRC), preceding history of hospitalization/ exacerbation over preceding one year and spirometric variables were recorded. Their stratification according to old and new classification recorded. Their past treatment records were reviewed and combined assessment if done recorded.

Results

Substantial shift of categories is seen from C and D respectively to stage A and B on applying the new classification compared to old i.e more severe to less severe. Secondly, revised combined assessment is still highly underutilized. Revised combined assessment has positive co-relation with spirometry and post bronchodilator forced expiratory volume in 1 second(FEV₁).

Conclusions

Management of substantial number of stable COPD patients may need to be stepped down in accordance with revised combined assessment. There is a need to disseminate information regarding change in COPD classification and stress on its incorporation in our day-to day clinical practice. Revised combined assessment has positive co-relation with spirometry, stressing its utility even in peripheral centers without spirometry facilities.

Classification and treatment of chronic obstructive pulmonary disease outpatients in China according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: comparison with GOLD 2014

Background

In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) proposed new classification criteria for patients with chronic obstructive pulmonary disease (COPD), which categorizes them into groups A-D based on risk of exacerbations and symptoms. The impact of the 2017 revisions on categorization and subsequent drug selection has been insufficiently studied in China.

Methods

This observational, multicenter, cross-sectional study recruited patients attending the outpatient clinics of 12 tertiary hospitals in China between April 2016 and July 2018. Patients were classified according to the GOLD 2014 and 2017 classification criteria and profiled based on categorization, demographics, clinical characteristics, and treatment regimens.

Results

In total, 1,278 COPD patients [mean age (±SD), 62.4±8.4 years; body mass index (BMI), 22.3±3.4 kg/m²] were included. According to the GOLD 2014 and 2017 classification criteria, the distribution in groups A-D was 58 (4.5%), 288 (22.5%), 28 (2.2%), 904 (70.7%) and 71 (5.6%), 573 (44.8%), 15 (1.2%), 619 (48.4%), respectively. Overall, 32% of patients in groups C-D were reclassified to groups A-B. Based on both GOLD 2014 and 2017, low BMI and education level were independent risk factors for high risk of exacerbation (i.e., being in groups C-D) (P<0.05). The patients who were reclassified from group D to B were younger and had fewer symptoms than those who remained in group D. The most frequently prescribed regimen was triple inhaled treatment (39.4%). Inhaled corticosteroids (ICS) were prescribed across all groups, and 205 (71.9%) of the 285 patients who were reclassified from group D to B were treated with ICS.

Conclusions

GOLD 2017 reclassified COPD patients to low-risk groups. The risk of exacerbation increased with decreased BMI or education levels. Overtreatment was observed in many patients, and physicians should reexamine treatment patterns for patients reclassified into low-risk groups.

What is the impact of GOLD 2017 recommendations in primary care? - a descriptive study of patient classifications, treatment burden and costs

PURPOSE

The changes in grading of disease severity and treatment recommendations for patients with COPD in the 2017 GOLD strategy may present an opportunity for reducing treatment burden for the patients and costs to the health care system. The aim of this study was to assess the implications of the GOLD 2017 grading system in terms of change in distribution across GOLD groups A-D for existing patients in UK primary care and estimate the potential cost savings of implementing GOLD 2017 treatment recommendations in UK primary care.

PATIENTS AND METHODS

Using electronic health record data from the Clinical Practice Research Datalink (CPRD), patients aged ≥35 years with spirometry-confirmed COPD, receiving care during 2016, were included. The cohort was graded according to the GOLD 2017 groups (A-D), and treatment costs were calculated, according to corresponding recommendations, to observe the difference in actual vs predicted costs.

RESULTS

When applying GOLD 2013 criteria, less than half of the cohort (46%) was assigned to GOLD A or B, as compared to 86% when applying the GOLD 2017 grading. The actual mean annual maintenance treatment cost was £542 per patient vs a predicted £389 for treatment according to the 2017 GOLD strategy.

CONCLUSION

There is a potential to make significant cost savings by implementing the grading and treatment recommendations from the 2017 GOLD strategy.

A proposal for the withdrawal of inhaled corticosteroids in the clinical practice of chronic obstructive pulmonary disease

According to the current clinical practice guidelines for chronic obstructive pulmonary disease (COPD), the addition of inhaled corticosteroids (ICS) to long-acting β2 agonist therapy is recommended in patients with moderate-to-severe disease and an increased risk of exacerbations. However, ICS are largely overprescribed in clinical practice, and most patients are unlikely to benefit from long-term ICS therapy.Evidence from recent randomized-controlled trials supports the hypothesis that ICS can be safely and effectively discontinued in patients with stable COPD and in whom ICS therapy may not be indicated, without detrimental effects on lung function, health status, or risk of exacerbations. This article summarizes the evidence supporting the discontinuation of ICS therapy, and proposes an algorithm for the implementation of ICS withdrawal in patients with COPD in clinical practice.Given the increased risk of potentially serious adverse effects and complications with ICS therapy (including pneumonia), the use of ICS should be limited to the minority of patients in whom the treatment effects outweigh the risks.

Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: Comparison with GOLD 2011

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project has been working to improve awareness, prevention and management of this disease. The aim of this study is to evaluate how COPD patients are reclassified by the 2017 GOLD system (versus GOLD 2011), to calculate the level of agreement between these two classifications in allocation to categories and to compare the performance of each classification to predict future exacerbations. Two-hundred COPD patients (>40 years, post bronchodilator forced expiratory volume in one second/forced vital capacity<0.7) followed in pulmonology consultation were recruited into this prospective multicentric study. Approximately half of the patients classified as GOLD D [2011] changed to GOLD B [2017]. The extent of agreement between GOLD 2011 and GOLD 2017 was moderate (Cohen's Kappa = 0.511; p < 0.001) and the ability to predict exacerbations was similar (69.7% and 67.6%, respectively). GOLD B [2017] exacerbated 17% more than GOLD B [2011] and had a lower percent predicted post bronchodilator forced expiratory volume in one second (FEV1). GOLD B [2017] turned to be the predominant category, more heterogeneous and with a higher risk of exacerbation versus GOLD B [2011]. Physicians should be cautious in assessing the GOLD B [2017] patients. The assessment of patients should always be personalized. More studies are needed to evaluate the impact of the 2017 reclassification in predicting outcomes such as future exacerbations and mortality.