Should Patients Switched from D to B in the GOLD 2017 Classification be Discontinued from Inhaled Corticosteroids?

Harlander, Matevž; Barrecheguren, Miriam; Turel, Matjaž; Miravitlles, Marc

doi:10.1080/15412555.2017.1342233

Cited by 20 publications

(17 citation statements)

References 30 publications

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“…It was concluded that ICS withdrawal can have a deleterious effect in COPD patients with severe airflow limitation, at least one moderate-to-severe exacerbation in the preceding year, and high peripheral blood eosinophilic count (4% or greater or ≥ 300 cell/µL). Harlander et al 21 observed that with the change in COPD classification of severity from GOLD 2013 to GOLD 2017, many patients would move from group D to group B. In fact, the GOLD 2017 classification did not take into account any more the severity of airflow limitation as a factor increasing, per se, the risk of exacerbations.…”

Section: Eosinophils In Peripheral Bloodmentioning

confidence: 99%

“…In fact, the GOLD 2017 classification did not take into account any more the severity of airflow limitation as a factor increasing, per se, the risk of exacerbations. The authors 21 conclude that withdrawal of ICS would be feasible in the group of patients moving from group D to B with the exclusion of patients with a suspected asthma-COPD overlap (ACO) and those with high peripheral blood eosinophils, suggesting ≥ 300 cells/µL as a cut-off count.…”

Section: Eosinophils In Peripheral Bloodmentioning

confidence: 99%

“…In particular, it has been shown that fluticasone can increase the risk of pneumonia [17][18][19] . Therefore, the combination of a widespread, potentially inappropriate prescription of ICS with the evidence of significant adverse effects has fueled the interest in the need for ICS withdrawal in COPD 6,7,20,21 . In table 1, the most common side effects associated with the regular use of ICS in COPD are listed.…”

Section: Introductionmentioning

confidence: 99%

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Pros and Cons of Inhaled Corticosteroids Withdrawal in Chronic Obstructive Pulmonary Disease

Rossi¹,

Zanardi²

2021

BRN

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Inhaled corticosteroids (ICS) are widely prescribed in chronic obstructive pulmonary disease (COPD) regardless of any guidance recommendation and of any stage of disease severity, either in fixed dose combination with a long-acting β 2-adrenergic agonist (LABA) or as a component of a triple therapy combination of different inhalers. However, the benefits of ICS in COPD are controversial. There is no recommendation for ICS in Global Initiative for Chronic Obstructive Lung Disease (GOLD) "low-risk" of exarcerbation patients and there are also limitations for those patients at "high-risk". Due to potential severe adverse effects, ICS should be discontinued in patients who do not need them. The safe withdrawal of ICS in COPD constitutes the main thrust of this article. We believe that ICS can be safely withdrawn in patients at low-risk. For patients at high risk of exacerbation, ICS may be discontinued with caution, monitoring changes in forced expiratory volume in one second (FEV 1) and in peripheral blood eosinophils. In all COPD patients, maintenance therapy with long-acting bronchodilators must be in place.

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Section: Eosinophils In Peripheral Bloodmentioning

confidence: 99%

Section: Eosinophils In Peripheral Bloodmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Pros and Cons of Inhaled Corticosteroids Withdrawal in Chronic Obstructive Pulmonary Disease

Rossi¹,

Zanardi²

2021

BRN

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“…61 Finally, eosinophil count cutoffs have been a controversial issue. 10,62 Authors of a recent review reported several barriers to the use of blood eosinophils to predict response to ICS therapy (eg, comorbidities, effort needed to calculate eosinophil counts, diurnal variation in individual blood eosinophil levels, and current medications and treatment) and recommended caution in its use as a biomarker. 63 Despite these inconsistencies, GOLD 2020 generally recommends blood eosinophil counts ≥300 cells/mL as a threshold for deciding ICS-based therapy; a threshold of ≥100 cells/mL can be considered in patients who have experienced ≥2 moderate exacerbations/year or ≥1 severe exacerbation requiring hospitalization in the preceding year.…”

Section: Eosinophils As Markers Of Response To Icsmentioning

confidence: 99%

Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease (COPD): Boon or Bane?

Kaplan

2020

J Am Board Fam Med

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Inhaled corticosteroid (ICS)-based therapy is often used for patients with chronic obstructive pulmonary disease (COPD). However, this approach is under scrutiny because of ICS overuse in patients for whom it is not recommended and because of concerns about adverse events, particularly pneumonia, with long-term ICS use. Evidence suggests ICS may be beneficial in specific patients, namely, those with high blood eosinophil counts (eg, ≥300 cells/mL) or who are at a high risk of exacerbations. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 ABCD assessment tool, these patients belong in group D. For these patients, recommended initial treatment includes ICS in combination with long-acting b 2-agonists (LABAs) when blood eosinophil counts are ≥300 cells/mL or LABA 1 long-acting muscarinic antagonist (LAMA) when patients are highly symptomatic, that is, with greater dyspnea and/or exercise limitation. Follow-up treatments for patients with persistent dyspnea and/or exacerbations may include LABA 1 ICS, LABA 1 LAMA, or LABA 1 LAMA 1 ICS, with use of ICS being guided by blood eosinophil counts. In this review, differences in the inflammatory mechanism underlying COPD and asthma and the role of ICS treatment in COPD are summarized. Furthermore, findings from recent clinical trials where use of ICS-based dual or triple therapy in COPD was compared with LABA 1 LAMA therapy and trials in which ICS withdrawal was evaluated in patients with COPD are reviewed. Finally, a step-by-step guide for ICS withdrawal in patients who are unlikely to benefit from this treatment is proposed. A video of the author discussing the overall takeaway of the review article could be downloaded from the link provided: https://www.youtube.com/watch?v=Uq7Sr5jqPDI.

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“…In addition, following the changes in the GOLD document 2017 update, in which impaired lung function is no longer considered as a determinant of exacerbation risk, a A c c e p t e d M a n u s c r i p t high number of COPD patients can now be labeled as group B (low risk of exacerbations and high level of symptoms) instead of D, and hence, no longer fulfill the indication for ICS. Since long-term therapy with ICS can result in side effects, the withdrawal of this treatment should be considered in this group of patients [21]. There is often a over-prescription of ICSs in stable COPD patients, particularly in COPD grades A or B, with considerable potential for harm [22,23] but there is also often, particularly in general practice, a misdiagnosis of bronchial asthma as COPD grades A or B [24][25][26][27][28].…”

Section: Several Large Controlled Clinical Trials Of Inhaled Combinatmentioning

confidence: 99%

Fluticasone furoate and vilanterol for the treatment of chronic obstructive pulmonary disease

Caramori

Ruggeri

Casolari³

et al. 2017

Expert Review of Respiratory Medicine

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Current national and international guidelines for the management of patients with stable chronic obstructive pulmonary disease (COPD) recommend the use of inhaled long-acting bronchodilators, inhaled glucocorticoids and their combinations for maintenance treatment of moderate to severe stable COPD. Areas covered: The role of fluticasone furoate (FF) and vilanterol (VI) once daily combination therapy for the regular treatment of patients with stable COPD is discussed in this review. Expert commentary: The regular treatment of moderate to severe stable COPD with once daily FF/VI combination therapy is effective, as seen in in several large placebo-controlled clinical trials involving many thousands of patients. FF/VI improved lung function, decreased respiratory symptoms and decreased the number of COPD exacerbations, including COPD-related hospitalizations. FF/VI combination therapy has also been approved for this indication in most countries. The use of this combination therapy may significantly decrease the economic costs for some National Health Services.

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Should Patients Switched from D to B in the GOLD 2017 Classification be Discontinued from Inhaled Corticosteroids?

Cited by 20 publications

References 30 publications

Pros and Cons of Inhaled Corticosteroids Withdrawal in Chronic Obstructive Pulmonary Disease

Pros and Cons of Inhaled Corticosteroids Withdrawal in Chronic Obstructive Pulmonary Disease

Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease (COPD): Boon or Bane?

Fluticasone furoate and vilanterol for the treatment of chronic obstructive pulmonary disease

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