&lt;p&gt;Inhaled Corticosteroids Prescribed for COPD Patients with Mild or Moderate Airflow Limitation: Who Warrants a Trial of Withdrawal?&lt;/p&gt;

Harries, Timothy H; Gilworth, Gill; Corrigan, Christopher; Murphy, Patrick B.; Hart, Nicholas; Thomas, Mike; White, Patrick

doi:10.2147/copd.s238239

Cited by 8 publications

(12 citation statements)

References 10 publications

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“…These results support the ATS and particularly the ERS guidelines that recommend discontinuation of ICS in patients without a history of frequent exacerbations and blood eosinophils < 300 cells/μL [14,15]. Despite the published studies and recommendations, ICS withdrawal is very infrequent in real life in primary care [31,32]. In our study, only 2% of patients on TT discontinued ICS during 1 year, which is similar to the 2% to 3.5% rates of discontinuation of ICS observed between 2014 and 2018 in another large primary care study in the UK [33].…”

Section: Discussionsupporting

confidence: 70%

“…Despite the published studies and recommendations, ICS withdrawal is very infrequent in real life in primary care [ 31 , 32 ]. In our study, only 2% of patients on TT discontinued ICS during 1 year, which is similar to the 2% to 3.5% rates of discontinuation of ICS observed between 2014 and 2018 in another large primary care study in the UK [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

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Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study

Magnussen

Lucas²,

Lapperre³

et al. 2021

Respir Res

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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).

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Section: Discussionsupporting

confidence: 70%

Section: Discussionmentioning

confidence: 99%

Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study

Magnussen

Lucas²,

Lapperre³

et al. 2021

Respir Res

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“…149 eligible patients were invited for clinical review. 23 61 patients attended the review.21 were excluded as a result of characteristics identi ed at the review, absent from their electronic records. 10 exhibited evidence suggestive of asthma (FEV 1 reversibility >15% and 400ml), 2 had suffered two or more moderate COPD exacerbations in the prior year, 7 had severe air ow limitation and 2 had normal spirometry.…”

Section: Resultsmentioning

confidence: 99%

“…21,22 We have previously reported a qualitative study of the acceptability of the intervention and a study of the method of identifying and recruiting participants. 10,23 Ethical approval for the study was obtained from the National Research Ethics Service,London -London Bridge Committee (16/LO/1696 -IRAS 172251).…”

Section: Methodsmentioning

confidence: 99%

Withdrawal of Inhaled Corticosteroids from COPD Patients with Mild or Moderate Airflow Limitation: Primary Care Feasibility Randomised Controlled Trial Reveals High Prevalence of Suspected Undiagnosed Asthma

Harries

Gilworth

Corrigan

et al. 2022

Preprint

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BackgroundInhaled corticosteroids (ICS) are frequently prescribedoutsideguidelines to COPD patients with mild or moderate airflow limitation and low exacerbation risk, despite little evidence of benefit and risk of adverse effects. This trial explored thefeasibilityof ICS withdrawalfrompatients with mild/moderate COPD in primary care.MethodsOpen, feasibility trial. Outcome measures included prevalence of suitable participants, sensitivity and specificity of their identification,their willingness to accept open randomisation to ICS withdrawal for up to 6 months or continuation with usual care.Results392 (13%) of 2967COPD patients from 20 practices (209,618 total population)identifiedas eligible for ICS withdrawalby algorithm electronic record search.Following individual record review, 243 (62%)deemedineligible because of (a)one severeor two moderate COPD exacerbations in previous year (86, 22%); (b)severe airflow limitation (65, 17%); (c) asthma (15, 4%); (d)other causes (77, 20%). Remainder (149)invited for assessment.61 attended and all agreed to randomisation to ICS withdrawal or usual care. At baseline assessment, 10 exhibitedairflow reversibility (forced expiratory volume (FEV)1 reversibility>12% and 200ml) which was a safety exclusion criterion, 2 had suffered ≥2 moderate exacerbations in prior year,7 had severe airflow limitation,2 had normal spirometry.40 were randomised.During ensuing 6 months, 1 patient died and another was lost to follow-up. 18 (45%) of the 38 (10 withdrawal, 8 usual care) exhibited previously undocumented FEV1variability consistent with asthma,supported bysignificant associations in ICS withdrawal group between FEV1 variability andelevated fractional exhaled nitric oxide (p=0.04), atopic history (p=0.01), elevated symptom score (p=0.04),poorerquality of life (p=0.04).ConclusionIdentifyingpatients with mild/moderate COPD suitable for ICS withdrawal was difficult because of poor recording of suitability criteria (undocumented exacerbations, unreliable lung function). Open, randomisation to ICS withdrawal or usual care was acceptableFollow-upretention at 6 months was excellent.Nearly 50% of participants with mild/moderate COPD and no previously recorded bronchodilator reversibility, demonstrated FEV1 variability during follow-up. In patients with mild/moderate COPD considered suitable for ICS withdrawal in primary care, surveillance of variability should be undertaken over at least 6 months. Trial registrationEudraCT Number: 2016-001876-31. Date registered: 5th August 2016.

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“… 21 , 22 It is difficult to assess accurately the frequency of COPD exacerbations due to their subjective nature and variation in their recording in the EHR. 23 Accessing data on exacerbations from EHRs can be complicated and time-consuming and the practice and accuracy of coding in primary care varies widely between individual clinicians. 24 Data on exacerbations often are entered in a free-text format and can only be retrieved by inspection of individual patient records, undermining the reliability of large-scale data searches.…”

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confidence: 99%

Spotlight on primary care management of COPD: Electronic health records

Harries

White

2021

Chron Respir Dis

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<p>Inhaled Corticosteroids Prescribed for COPD Patients with Mild or Moderate Airflow Limitation: Who Warrants a Trial of Withdrawal?</p>

Cited by 8 publications

References 10 publications

Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study

Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study

Withdrawal of Inhaled Corticosteroids from COPD Patients with Mild or Moderate Airflow Limitation: Primary Care Feasibility Randomised Controlled Trial Reveals High Prevalence of Suspected Undiagnosed Asthma

Spotlight on primary care management of COPD: Electronic health records

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