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Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice.

Kaplan AG - Int J Chron Obstruct Pulmon Dis (2015)

Bottom Line: In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS.Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms.Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal.

View Article: PubMed Central - PubMed

Affiliation: Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada ; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.

ABSTRACT
Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.

No MeSH data available.


Related in: MedlinePlus

GOLD recommendations for the pharmacologic management of stable COPD according to the four GOLD groups of COPD, which are based on a combined assessment of symptoms and exacerbation risk.Note: Adapted by the author from the Global Strategy for Diagnosis, Management and Prevention of COPD 2015, © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from http://www.goldcopd.org.2Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; PDE-4i, phosphodiesterase-4 inhibitor; prn, as needed; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic antagonist.
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f1-copd-10-2535: GOLD recommendations for the pharmacologic management of stable COPD according to the four GOLD groups of COPD, which are based on a combined assessment of symptoms and exacerbation risk.Note: Adapted by the author from the Global Strategy for Diagnosis, Management and Prevention of COPD 2015, © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from http://www.goldcopd.org.2Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; PDE-4i, phosphodiesterase-4 inhibitor; prn, as needed; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic antagonist.

Mentions: Although ICS have been long used in the management of COPD, evidence supporting their use has been considered equivocal and their positioning in guidelines as controversial. According to the latest 2015 update of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, ICS in combination with a long-acting β2-agonist (LABA) and/or long-acting muscarinic antagonist (LAMA) is the first recommended choice for patients with a high-risk of exacerbations (Groups C and D; Figure 1).2 In addition to this international “gold standard” guideline, a number of national and multinational guidelines exist; however, their recommendations pertaining to the use of ICS are inconsistent with those of the GOLD report, in part, due to the varying criteria for categorizing patients with COPD and different interpretations of the equivocal evidence supporting ICS use.1,3–7 Despite this, there is consensus that ICS are indicated in combination with long-acting bronchodilators (LABDs) for patients with COPD at risk of exacerbations and/or in those with asthma–COPD overlap syndrome (ACOS), but never as monotherapy.


Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice.

Kaplan AG - Int J Chron Obstruct Pulmon Dis (2015)

GOLD recommendations for the pharmacologic management of stable COPD according to the four GOLD groups of COPD, which are based on a combined assessment of symptoms and exacerbation risk.Note: Adapted by the author from the Global Strategy for Diagnosis, Management and Prevention of COPD 2015, © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from http://www.goldcopd.org.2Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; PDE-4i, phosphodiesterase-4 inhibitor; prn, as needed; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic antagonist.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4664433&req=5

f1-copd-10-2535: GOLD recommendations for the pharmacologic management of stable COPD according to the four GOLD groups of COPD, which are based on a combined assessment of symptoms and exacerbation risk.Note: Adapted by the author from the Global Strategy for Diagnosis, Management and Prevention of COPD 2015, © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from http://www.goldcopd.org.2Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; PDE-4i, phosphodiesterase-4 inhibitor; prn, as needed; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic antagonist.
Mentions: Although ICS have been long used in the management of COPD, evidence supporting their use has been considered equivocal and their positioning in guidelines as controversial. According to the latest 2015 update of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, ICS in combination with a long-acting β2-agonist (LABA) and/or long-acting muscarinic antagonist (LAMA) is the first recommended choice for patients with a high-risk of exacerbations (Groups C and D; Figure 1).2 In addition to this international “gold standard” guideline, a number of national and multinational guidelines exist; however, their recommendations pertaining to the use of ICS are inconsistent with those of the GOLD report, in part, due to the varying criteria for categorizing patients with COPD and different interpretations of the equivocal evidence supporting ICS use.1,3–7 Despite this, there is consensus that ICS are indicated in combination with long-acting bronchodilators (LABDs) for patients with COPD at risk of exacerbations and/or in those with asthma–COPD overlap syndrome (ACOS), but never as monotherapy.

Bottom Line: In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS.Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms.Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal.

View Article: PubMed Central - PubMed

Affiliation: Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada ; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.

ABSTRACT
Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.

No MeSH data available.


Related in: MedlinePlus