Inhaled corticosteroids and the risk of a first exacerbation in COPD patients

Abstract

Inhaled corticosteroids and the risk of a first exacerbation in COPD patients. M.N. de Melo, P. Ernst, S. Suissa. #ERS Journals Ltd 2004. ABSTRACT: The role of inhaled corticosteroids (ICS) in asthma is well established, but their benefit in the management of chronic obstructive pulmonary disease (COPD) is still controversial. The current study assessed whether ICS are effective in preventing a first exacerbation of COPD.A cohort of newly treated COPD patients was formed from the Administrative Databases of Saskatchewan Health. The outcome was the occurrence of a first moderate or severe exacerbation from 1990-1999. Moderate exacerbations involved prescriptions for an antibiotic and an oral corticosteroid on the same day. Severe exacerbations were hospitalisations with a primary discharge diagnosis of COPD. A nested case-control design was used and matched on year of birth and cohort entry. Rate ratios (RR) were further adjusted for use of other medication and other confounders.There were 995 exacerbations among 4,455 subjects. The rate of a first exacerbation was increased with any use of ICS in the year prior to the index date (RR: 1.27; 95% CI: 1.08-1.48) and with current use (RR: 1.51; 95% CI: 1.22-1.87), and it increased with increasing daily doses of ICS.Inhaled corticosteroids do not seem to be beneficial in reducing the risk of a first exacerbation of chronic obstructive pulmonary disease.

From the authors

“…We read with great interest the article by LUIJK et al These findings would further support the current opinion that airway responsiveness to AMP is more sensitive than eNO, together with other noninvasive markers of airway inflammation, in assessing the response to anti-inflammatory treatments [2,3]. To this end, it must be emphasised that inhaled glucocorticosteroids (GCS) have been shown to increase the provocative concentration causing a 20% fall in forced expiratory volume in one second (PC20) threshold of AMP in a dose-dependent manner, whereas the dose response for eNO, together with many other inflammatory markers, and measures of lung function have all been shown to exhibit a plateau effect at lower doses [4].…”

“…To maximally ensure the accuracy of a first-time COPD diagnosis for cohort entry, we used three criteria: 1) 55 yrs of age or over; 2) three or more prescriptions on at least two different dates for a bronchodilator within a 1-yr period; and 3) no other prescriptions for bronchodilators or other asthma drugs during the 5-yr period prior to the three defining prescriptions [1,2]. With these criteria, we were confident that the proportion of asthma patients would be kept to a negligible level.…”

“…This is particularly important when assessing the impact of inhaled corticosteroids because these drugs have been shown in randomised trials to be extremely effective in asthma but not in COPD. Thus, a study based on a mixed population that includes both asthma and COPD patients will result in an average effect for inhaled corticosteroids.To maximally ensure the accuracy of a first-time COPD diagnosis for cohort entry, we used three criteria: 1) 55 yrs of age or over; 2) three or more prescriptions on at least two different dates for a bronchodilator within a 1-yr period; and 3) no other prescriptions for bronchodilators or other asthma drugs during the 5-yr period prior to the three defining prescriptions [1,2]. With these criteria, we were confident that the proportion of asthma patients would be kept to a negligible level.…”

Predictive Model of Hospital Admission for COPD Exacerbation

“…16,[18][19][20] The model also takes into account the protective effect of influenza immunization in subjects with more severe forms of disease and the lower admission rates in women.…”

“…15,16 The study population was old and mainly male, probably because smoking started late in women in our setting. 16 The predictive factors of hospital admission in our study, such as old age, 16 history of smoking, 17,18 comorbidities, 18,19 severity of disease (GOLD), 7 and previous admissions for exacerbation, 20 have already been described.…”