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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 Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients.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

A proposed step-by-step algorithm for safely withdrawing ICS from patients with COPD in real-life clinical practice.Abbreviations: ACOS, asthma–COPD overlap syndrome; CAT, COPD Assessment Test; CCQ9, Chronic COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; ppb, parts per billion.
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f2-copd-10-2535: A proposed step-by-step algorithm for safely withdrawing ICS from patients with COPD in real-life clinical practice.Abbreviations: ACOS, asthma–COPD overlap syndrome; CAT, COPD Assessment Test; CCQ9, Chronic COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; ppb, parts per billion.

Mentions: Currently, no national or international clinical guidelines advocate withdrawal of ICS nor do they provide recommendations regarding the safe withdrawal of ICS in patients with COPD. For reasons previously described, there is an urgent need for a step-by-step algorithm that can be applied in real-life clinical practice. Figure 2 proposes such an algorithm and attempts to address the following questions: 1) In which patients is ICS withdrawal safe? and 2) How to withdraw ICS in appropriate patients? This algorithm takes into account not only exacerbation risk, as per GOLD, but also the emerging, neglected ACOS phenotype, as per the GINA/GOLD Consensus Statement. Potential markers of eosinophilia are also considered and noted as optional, as these are still theoretical and need to be tested in RCTs. Furthermore, the stepwise ICS withdrawal protocol on top of maintenance therapy with dual bronchodilation is primarily based on the WISDOM trial, although, instead of down-titrating ICS every 6 weeks, it is proposed that physicians consider stepping down ICS dose every 6–12 weeks. The rationale for this is to ensure that the effects of ICS in the inflammation cascade of COPD have been optimized on a physiological level,72 and from a practical perspective, permit enough time to monitor for potential exacerbations. In regards to optimizing bronchodilation following ICS withdrawal, we are now more equipped than ever before with a larger armamentarium of novel LABA + LAMA combinations that clinicians can consider for more effective bronchodilation maintenance (Table 3).


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)

A proposed step-by-step algorithm for safely withdrawing ICS from patients with COPD in real-life clinical practice.Abbreviations: ACOS, asthma–COPD overlap syndrome; CAT, COPD Assessment Test; CCQ9, Chronic COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; ppb, parts per billion.
© Copyright Policy
Related In: Results  -  Collection

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

f2-copd-10-2535: A proposed step-by-step algorithm for safely withdrawing ICS from patients with COPD in real-life clinical practice.Abbreviations: ACOS, asthma–COPD overlap syndrome; CAT, COPD Assessment Test; CCQ9, Chronic COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council Dyspnea Scale; ppb, parts per billion.
Mentions: Currently, no national or international clinical guidelines advocate withdrawal of ICS nor do they provide recommendations regarding the safe withdrawal of ICS in patients with COPD. For reasons previously described, there is an urgent need for a step-by-step algorithm that can be applied in real-life clinical practice. Figure 2 proposes such an algorithm and attempts to address the following questions: 1) In which patients is ICS withdrawal safe? and 2) How to withdraw ICS in appropriate patients? This algorithm takes into account not only exacerbation risk, as per GOLD, but also the emerging, neglected ACOS phenotype, as per the GINA/GOLD Consensus Statement. Potential markers of eosinophilia are also considered and noted as optional, as these are still theoretical and need to be tested in RCTs. Furthermore, the stepwise ICS withdrawal protocol on top of maintenance therapy with dual bronchodilation is primarily based on the WISDOM trial, although, instead of down-titrating ICS every 6 weeks, it is proposed that physicians consider stepping down ICS dose every 6–12 weeks. The rationale for this is to ensure that the effects of ICS in the inflammation cascade of COPD have been optimized on a physiological level,72 and from a practical perspective, permit enough time to monitor for potential exacerbations. In regards to optimizing bronchodilation following ICS withdrawal, we are now more equipped than ever before with a larger armamentarium of novel LABA + LAMA combinations that clinicians can consider for more effective bronchodilation maintenance (Table 3).

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