1
|
Magnussen H, Lucas S, Lapperre T, Quint JK, Dandurand RJ, Roche N, Papi A, Price D, Miravitlles M. Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study. Respir Res 2021; 22:25. [PMID: 33478491 PMCID: PMC7818945 DOI: 10.1186/s12931-021-01615-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are indicated for prevention of exacerbations in patients with COPD, but they are frequently overprescribed. ICS withdrawal has been recommended by international guidelines in order to prevent side effects in patients in whom ICS are not indicated. METHOD Observational comparative effectiveness study aimed to evaluate the effect of ICS withdrawal versus continuation of triple therapy (TT) in COPD patients in primary care. Data were obtained from the Optimum Patient Care Research Database (OPCRD) in the UK. RESULTS A total of 1046 patients who withdrew ICS were matched 1:4 by time on TT to 4184 patients who continued with TT. Up to 76.1% of the total population had 0 or 1 exacerbation the previous year. After controlling for confounders, patients who discontinued ICS did not have an increased risk of moderate or severe exacerbations (adjusted HR: 1.04, 95% confidence interval (CI) 0.94-1.15; p = 0.441). However, rates of exacerbations managed in primary care (incidence rate ratio (IRR) 1.33, 95% CI 1.10-1.60; p = 0.003) or in hospital (IRR 1.72, 95% CI 1.03-2.86; p = 0.036) were higher in the cessation group. Unsuccessful ICS withdrawal was significantly and independently associated with more frequent courses of oral corticosteroids the previous year and with a blood eosinophil count ≥ 300 cells/μL. CONCLUSIONS In this primary care population of patients with COPD, composed mostly of infrequent exacerbators, discontinuation of ICS from TT was not associated with an increased risk of exacerbation; however, the subgroup of patients with more frequent courses of oral corticosteroids and high blood eosinophil counts should not be withdrawn from ICS. Trial registration European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS30851).
Collapse
Affiliation(s)
- Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Member of the German Center of Lung Research, Grosshansdorf, Germany
| | | | - Therese Lapperre
- Department of Respiratory Medicine, Antwerp University Hospital, Edegem, Denmark
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, UK
| | - Jennifer K Quint
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, UK
| | - Ronald J Dandurand
- CIUSSS de L'Ouest-de-L'Île-de-Montréal, Montreal Chest Institute, Meakins-Christie Laboratories, Oscillometry Unit and Centre for Innovative Medicine, McGill University Health Centre and Research Institute, Montreal, QC, Canada
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University of Paris, UMR1016, Cochin Institute, Paris, France
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall D'Hebron, Vall D'Hebron Institut de Recerca (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| |
Collapse
|
2
|
Chapman KR, Hurst JR, Frent SM, Larbig M, Fogel R, Guerin T, Banerji D, Patalano F, Goyal P, Pfister P, Kostikas K, Wedzicha JA. Long-Term Triple Therapy De-escalation to Indacaterol/Glycopyrronium in Patients with Chronic Obstructive Pulmonary Disease (SUNSET): A Randomized, Double-Blind, Triple-Dummy Clinical Trial. Am J Respir Crit Care Med 2019; 198:329-339. [PMID: 29779416 DOI: 10.1164/rccm.201803-0405oc] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE There are no studies on withdrawal of inhaled corticosteroids in patients on long-term triple therapy in the absence of frequent exacerbations. OBJECTIVES To evaluate the efficacy and safety of direct de-escalation from long-term triple therapy to indacaterol/glycopyrronium in nonfrequently exacerbating patients with chronic obstructive pulmonary disease (COPD). METHODS This 26-week, randomized, double-blind, triple-dummy study assessed the direct change from long-term triple therapy to indacaterol/glycopyrronium (110/50 μg once daily) or continuation of triple therapy (tiotropium [18 μg] once daily plus combination of salmeterol/fluticasone propionate [50/500 μg] twice daily) in nonfrequently exacerbating patients with moderate-to-severe COPD. Primary endpoint was noninferiority on change from baseline in trough FEV1. Moderate or severe exacerbations were predefined secondary endpoints. MEASUREMENTS AND MAIN RESULTS A total of 527 patients were randomized to indacaterol/glycopyrronium and 526 to triple therapy. Inhaled corticosteroids withdrawal led to a reduction in trough FEV1 of -26 ml (95% confidence interval, -53 to 1 ml) with confidence limits exceeding the noninferiority margin of -50 ml. The annualized rate of moderate or severe COPD exacerbations did not differ between treatments (rate ratio, 1.08; 95% confidence interval, 0.83 to 1.40). Patients with ≥300 blood eosinophils/μl at baseline presented greater lung function loss and higher exacerbation risk. Adverse events were similar in the two groups. CONCLUSIONS In patients with COPD without frequent exacerbations on long-term triple therapy, the direct de-escalation to indacaterol/glycopyrronium led to a small decrease in lung function, with no difference in exacerbations. The higher exacerbation risk in patients with ≥300 blood eosinophils/μl suggests that these patients are likely to benefit from triple therapy. Clinical trial registered with www.clinicaltrials.gov (NCT 02603393).
Collapse
Affiliation(s)
- Kenneth R Chapman
- 1 Asthma and Airway Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - John R Hurst
- 2 UCL Respiratory, University College London, London, United Kingdom
| | - Stefan-Marian Frent
- 3 Department of Pulmonology, University of Medicine and Pharmacy, Timisoara, Romania
| | | | - Robert Fogel
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Tadhg Guerin
- 6 Novartis Ireland Limited, Dublin, Ireland; and
| | - Donald Banerji
- 5 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | | | - Jadwiga A Wedzicha
- 7 Respiratory Clinical Science Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| |
Collapse
|
3
|
Avdeev S, Aisanov Z, Arkhipov V, Belevskiy A, Leshchenko I, Ovcharenko S, Shmelev E, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms. Int J Chron Obstruct Pulmon Dis 2019; 14:1267-1280. [PMID: 31354256 PMCID: PMC6572750 DOI: 10.2147/copd.s207775] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/17/2019] [Indexed: 12/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sergey Avdeev
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation.,Clinical Department, Federal Pulmonology Research Institute, Federal Medical and Biological Agency of Russia, Moscow, Russian Federation
| | - Zaurbek Aisanov
- Department of Pulmonology, N.I. Pirogov Russian State National Research Medical University, Moscow, Russian Federation
| | - Vladimir Arkhipov
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Andrey Belevskiy
- Department of Pulmonology, N.I. Pirogov Russian State National Research Medical University, Moscow, Russian Federation
| | - Igor Leshchenko
- Department of Phthisiology, Pulmonology and Thoracic Surgery, Ural State Medical University, Ekaterinburg, Russian Federation
| | - Svetlana Ovcharenko
- Department of Internal Diseases No.1, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Evgeny Shmelev
- Department of Differential Diagnostics, Federal Central Research Institute of Tuberculosis, Moscow, Russian Federation
| | - Marc Miravitlles
- Pneumology Department, University Hospital Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| |
Collapse
|
4
|
Chapman KR, Hurst JR, Fogel RB, Pfister P, Kostikas K, Wedzicha JA. Reply to Lan and Shi: Different Background, Short Duration, and Inappropriate Participants May Harm Your Conclusion. Am J Respir Crit Care Med 2019; 199:390-392. [DOI: 10.1164/rccm.201809-1776le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Robert B. Fogel
- Novartis Pharmaceuticals CorporationEast Hanover, New Jersey
| | | | | | | |
Collapse
|
5
|
Agusti A, Fabbri LM, Singh D, Vestbo J, Celli B, Franssen FME, Rabe KF, Papi A. Inhaled corticosteroids in COPD: friend or foe? Eur Respir J 2018; 52:13993003.01219-2018. [PMID: 30190269 DOI: 10.1183/13993003.01219-2018] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/23/2018] [Indexed: 12/28/2022]
Abstract
The efficacy, safety and positioning of inhaled corticosteroids (ICS) in the treatment of patients with chronic obstructive pulmonary disease (COPD) is much debated, since it can result in clear clinical benefits in some patients ("friend") but can be ineffective or even associated with undesired side effects, e.g. pneumonia, in others ("foe"). After critically reviewing the evidence for and against ICS treatment in patients with COPD, we propose that: 1) ICS should not be used as a single, stand-alone therapy in COPD; 2) patients most likely to benefit from the addition of ICS to long-acting bronchodilators include those with history of multiple or severe exacerbations despite appropriate maintenance bronchodilator use, particularly if blood eosinophils are >300 cells·µL-1, and those with a history of and/or concomitant asthma; and 3) the risk of pneumonia in COPD patients using ICS is higher in those with older age, lower body mass index (BMI), greater overall fragility, receiving higher ICS doses and those with blood eosinophils <100 cells·µL-1 All these factors must be carefully considered and balanced in any individual COPD patient before adding ICS to her/his maintenance bronchodilator treatment. Further research is needed to clarify some of these issues and firmly establish these recommendations.
Collapse
Affiliation(s)
- Alvar Agusti
- Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBER Enfermedades Respiratorias, Spain
| | - Leonardo M Fabbri
- Dept of Medicine, University of Ferrara, Ferrara, Italy.,COPD Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,Medicines Evaluation Unit, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Bartolome Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Frits M E Franssen
- Dept of Research and Education, CIRO, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Klaus F Rabe
- LungenClinic Großhansdorf, member of the German Center for Lung Research (DZL), Großhansdorf, Germany.,Christian Albrechts Universität Kiel, member of the German Center for Lung Research (DZL), Kiel, Germany
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| |
Collapse
|
6
|
Pharmacological Therapy of COPD. Chest 2018; 154:1404-1415. [DOI: 10.1016/j.chest.2018.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022] Open
|
7
|
Lopez-Campos JL, Carrasco Hernández L, Muñoz X, Bustamante V, Barreiro E. Current controversies in the stepping up and stepping down of inhaled therapies for COPD at the patient level. Respirology 2018; 23:818-827. [PMID: 29924458 DOI: 10.1111/resp.13341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/23/2022]
Abstract
The implementation of potential new step-up or step-down treatment recommendations in response to current guidelines is one of the main challenges currently faced in actual daily practice settings. In the present narrative review, we aim to discuss the relevance of these step-up and step-down proposals at the patient level in daily clinical practice. In particular, we aim to review the challenges associated with inhaled maintenance therapy for chronic obstructive pulmonary disease (COPD) in four clinical scenarios. First, we discuss the step up from single to double bronchodilation, including current controversies regarding the addition of a second bronchodilator versus initial treatment with two bronchodilators. Second, we discuss the step up from double bronchodilation to triple therapy while challenging current indications for inhaled steroid therapy and discussing triple therapy designs. Third, we discuss the step down from triple therapy to double bronchodilation while evaluating the effect of this downshift in risk categories on the patient according to the new classifications. Finally, we discuss the step down from double to single bronchodilation, with a special focus on safety. We believe this review will help to highlight the most relevant discussion points regarding the treatment of COPD in a manner that will stimulate and guide related clinical research.
Collapse
Affiliation(s)
- Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Laura Carrasco Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Xavier Muñoz
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Service, Department of Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Víctor Bustamante
- Servicio de Neumología, Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, EHU-University of the Basque Country, Vizcaya, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department (CEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
| |
Collapse
|
8
|
D'Urzo AD, Kardos P, Wiseman R. Practical considerations when prescribing a long-acting muscarinic antagonist for patients with COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1089-1104. [PMID: 29670345 PMCID: PMC5894726 DOI: 10.2147/copd.s160577] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
COPD is characterized by persistent airflow limitation, progressive breathlessness, cough, and sputum production. Long-acting muscarinic antagonists (LAMAs) are one of the recommended first-choice therapeutic options for patients with COPD, and several new agents have been developed in recent years. A literature search identified 14 published randomized, placebo-controlled studies of the efficacy and safety of LAMAs in patients with COPD, with improvements seen in lung function, exacerbations, breathlessness, and health status. A greater weight of evidence currently exists for glycopyrronium (GLY) and tiotropium than for umeclidinium and aclidinium, especially in terms of exacerbation reductions. To date, there have been few head-to-head clinical studies of the different LAMAs. Available data indicate that GLY and aclidinium have similar efficacy to tiotropium in terms of improving lung function, dyspnea, exacerbations, and health status. Overall, evidence demonstrates that currently available LAMAs provide effective and generally well-tolerated therapy for patients with COPD. Delivery devices for the different LAMAs vary, which may affect individual patient's adherence to and preference for treatment. Subtle differences between individual therapeutic options may be important to individual patients and the final treatment choice should involve physician's and patient's experiences and preferences.
Collapse
Affiliation(s)
- Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, ON, Canada
| | - Peter Kardos
- Group Practice and Centre for Allergy, Respiratory and Sleep Medicine, Red Cross Maingau Hospital, Frankfurt, Germany
| | | |
Collapse
|
9
|
Ariel A, Altraja A, Belevskiy A, Boros PW, Danila E, Fležar M, Koblizek V, Fridlender ZG, Kostov K, Krams A, Milenkovic B, Somfay A, Tkacova R, Tudoric N, Ulmeanu R, Valipour A. Inhaled therapies in patients with moderate COPD in clinical practice: current thinking. Int J Chron Obstruct Pulmon Dis 2017; 13:45-56. [PMID: 29317810 PMCID: PMC5743110 DOI: 10.2147/copd.s145573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COPD is a complex, heterogeneous condition. Even in the early clinical stages, COPD carries a significant burden, with breathlessness frequently leading to a reduction in exercise capacity and changes that correlate with long-term patient outcomes and mortality. Implementation of an effective management strategy is required to reduce symptoms, preserve lung function, quality of life, and exercise capacity, and prevent exacerbations. However, current clinical practice frequently differs from published guidelines on the management of COPD. This review focuses on the current scientific evidence and expert opinion on the management of moderate COPD: the symptoms arising from moderate airflow obstruction and the burden these symptoms impose, how physical activity can improve disease outcomes, the benefits of dual bronchodilation in COPD, and the limited evidence for the benefits of inhaled corticosteroids in this disease. We emphasize the importance of maximizing bronchodilation in COPD with inhaled dual-bronchodilator treatment, enhancing patient-related outcomes, and enabling the withdrawal of inhaled corticosteroids in COPD in well-defined patient groups.
Collapse
Affiliation(s)
- Amnon Ariel
- Emek Medical Center, Clalit Healthcare Services, Afula, Israel
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Andrey Belevskiy
- Department of Pulmonology, Russian National Research Medical University, Moscow, Russia
| | - Piotr W Boros
- Lung Pathophysiology Department, National TB and Lung Diseases Research Institute, Warsaw, Poland
| | - Edvardas Danila
- Clinic of Infectious Chest Diseases, Dermatovenereology, and Allergology, Vilnius University, Centre of Pulmonology and Allergology, Vilnius University Hospital, Vilnius, Lithuania
| | - Matjaz Fležar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Vladimir Koblizek
- Department of Pneumology, University Hospital, Hradec Králové, Czech Republic
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Kosta Kostov
- Clinic of Pulmonary Diseases, Military Medical Academy, Sofia, Bulgaria
| | - Alvils Krams
- Medical Faculty of Latvian University, Riga East University Hospital, Riga, Latvia
| | - Branislava Milenkovic
- Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Attila Somfay
- Department of Pulmonology, University of Szeged, Deszk, Hungary
| | - Ruzena Tkacova
- Department of Respiratory Medicine and Tuberculosis, Faculty of Medicine, PJ Safarik University, Košice, Slovakia
| | - Neven Tudoric
- School of Medicine, Dubrava University Hospital, Zagreb, Croatia
| | | | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
| |
Collapse
|
10
|
Miravitlles M, Cosío BG, Arnedillo A, Calle M, Alcázar-Navarrete B, González C, Esteban C, Trigueros JA, Rodríguez González-Moro JM, Quintano Jiménez JA, Baloira A. A proposal for the withdrawal of inhaled corticosteroids in the clinical practice of chronic obstructive pulmonary disease. Respir Res 2017; 18:198. [PMID: 29183382 PMCID: PMC5706374 DOI: 10.1186/s12931-017-0682-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/15/2017] [Indexed: 01/24/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, P. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Borja G Cosío
- CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Department of Respiratory Medicine, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Spain
| | - Aurelio Arnedillo
- Pneumology, Allergy and Thoracic Surgery Department, Hospital Universitario Puerta del Mar, Cádiz, Spain
- Medicine Department, University of Cádiz, Cádiz, Spain
| | - Myriam Calle
- Pulmonary Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Bernardino Alcázar-Navarrete
- Respiratory Department, AIG de Medicina, Hospital de Alta Resolución de Loja, Agencia Sanitaria Hospital de Poniente, Loja, Granada, Spain
| | - Cruz González
- Department of Respiratory Medicine, Hospital Clínico Universitario and Instituto de Investigación Sanitaria (INCLIVA) Valencia, Valencia, Spain
| | - Cristóbal Esteban
- Pneumology Department of Hospital Galdakao-Usansolo, Biscay, Spain
- Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Bilbao, Spain
| | | | | | | | - Adolfo Baloira
- Servicio de Neumología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| |
Collapse
|
11
|
Calverley PMA, Magnussen H, Miravitlles M, Wedzicha JA. Triple Therapy in COPD: What We Know and What We Don't. COPD 2017; 14:648-662. [DOI: 10.1080/15412555.2017.1389875] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Centre for Lung Research, Grosshansdorf, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Jadwiga A. Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
12
|
[The effects of inhaled steroids withdrawal in COPD]. Rev Mal Respir 2017; 34:820-833. [PMID: 28506728 DOI: 10.1016/j.rmr.2016.10.880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 10/26/2016] [Indexed: 11/21/2022]
Abstract
The key pathophysiological feature of chronic obstructive pulmonary disease (COPD) is an abnormal inflammatory bronchial reaction after inhalation of toxic substances. The priority is the avoidance of such toxic inhalations, but the use of anti-inflammatory drugs also seems appropriate, especially corticosteroids that are the sole anti-inflammatory drug available for this purpose in France. The risks associated with the prolonged use of these parenteral drugs are well known. Inhalation is therefore the optimal route, but inhaled drugs may also lead to adverse consequences. In COPD, there is an inhaled corticosteroids overuse, and a non-satisfactory respect of the guidelines. Consequently, their withdrawal should be considered. We reviewed seven clinical studies dealing with inhaled corticosteroids withdrawal in patients with COPD and found that included populations were heterogenous with different concomitant treatments. In non-frequent exacerbators receiving inhaled corticosteroids outside the recommendations, withdrawal appears to be safe under a well-managed bronchodilator treatment. In patients with severe COPD and frequent exacerbations, the risk of acute respiratory event is low when they receive concomitant optimal inhaled bronchodilators. However, other risks may be observed (declining lung function, quality of life) and a discussion of each case should be performed, especially in case of COPD and asthma overlap.
Collapse
|
13
|
Calverley PM. Through a glass darkly: inhaled corticosteroids, airway inflammation and COPD. Eur Respir J 2017; 49:49/1/1602201. [DOI: 10.1183/13993003.02201-2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/15/2016] [Indexed: 11/05/2022]
|
14
|
Rodriguez-Roisin R, Tetzlaff K, Watz H, Wouters EF, Disse B, Finnigan H, Magnussen H, Calverley PM. Daily home-based spirometry during withdrawal of inhaled corticosteroid in severe to very severe chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2016; 11:1973-81. [PMID: 27578972 PMCID: PMC5001655 DOI: 10.2147/copd.s106142] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The WISDOM study (NCT00975195) reported a change in lung function following withdrawal of fluticasone propionate in patients with severe to very severe COPD treated with tiotropium and salmeterol. However, little is known about the validity of home-based spirometry measurements of lung function in COPD. Therefore, as part of this study, following suitable training, patients recorded daily home-based spirometry measurements in addition to undergoing periodic in-clinic spirometric testing throughout the study duration. We subsequently determined the validity of home-based spirometry for detecting changes in lung function by comparing in-clinic and home-based forced expiratory volume in 1 second in patients who underwent stepwise fluticasone propionate withdrawal over 12 weeks versus patients remaining on fluticasone propionate for 52 weeks. Bland–Altman analysis of these data confirmed good agreement between in-clinic and home-based measurements, both across all visits and at the individual visits at study weeks 6, 12, 18, and 52. There was a measurable difference between the forced expiratory volume in 1 second values recorded at home and in the clinic (mean difference of −0.05 L), which may be due to suboptimal patient effort in performing unsupervised recordings. However, this difference remained consistent over time. Overall, these data demonstrate that home-based and in-clinic spirometric measurements were equally valid and reliable for assessing lung function in patients with COPD, and suggest that home-based spirometry may be a useful tool to facilitate analysis of changes in lung function on a day-to-day basis.
Collapse
Affiliation(s)
- Roberto Rodriguez-Roisin
- Respiratory Institute, Servei de Pneumologia, Hospital Clínic IDIBAPS-CIBERES, Universitat de Barcelona, Barcelona, Spain
| | - Kay Tetzlaff
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany; Department of Sports Medicine, University of Tübingen, Tübingen, Germany
| | - Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Emiel Fm Wouters
- Department of Respiratory Medicine, University Hospital Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Bernd Disse
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Helen Finnigan
- Department of Biostatistics and Data Sciences, Boehringer Ingelheim, Bracknell, UK
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Peter Ma Calverley
- Institute of Ageing and Chronic Disease, Aintree University Hospital, Liverpool, UK
| |
Collapse
|
15
|
Bhatt SP. Eosinophils in COPD: the Janus of phenotyping response to therapy? THE LANCET RESPIRATORY MEDICINE 2016; 4:681-683. [PMID: 27460164 DOI: 10.1016/s2213-2600(16)30190-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Birmingham, AL 35294, USA; UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| |
Collapse
|