Step-Up and Step-Down Treatment Approaches for COPD: A Holistic View of Progressive Therapies

Abstract

Recent advances in inhaled drugs and a clearer definition of the disease have made the task of managing COPD more complex. Different proposals have been put forward which combine all the available treatments and the different clinical presentations in an effort to select the best therapeutic options for each clinical context. As COPD is a chronic progressive disease, the escalation of therapy has traditionally been considered the most natural way to tackle it. However, the notion of COPD as a constantly progressing disease has recently been challenged and, in specific areas, this points to the possibility of a deescalation in treatment. In this context, the clinician requires simple, specific recommendations to guide these changes in treatment in their daily clinical practice. To accomplish this, the first step must be a correct evaluation and an accurate initial preliminary diagnosis of the patient's condition. Thereafter, the first escalation in therapy must be introduced with caution as the disease progresses, since clinical trials are not designed with clinical decision-making in mind. During this escalation, three possibilities are open to change the current treatment for a different one within the same family, to increase non-pharmacological interventions or to increase the pharmacological therapies. Beyond that point, a patient with persistent symptoms represents a complex clinical scenario which requires a specialized approach, including the evaluation of different respiratory and non-respiratory comorbidities. Unfortunately, there are few de-escalation studies available, and these are mainly observational in nature. The debate on de-escalation in pharmacological treatment, therefore, involves two main discussion points: the withdrawal of bronchodilators and the withdrawal of inhaled steroids. Altogether, the scheme for modifying treatment must be more personalized than just adding molecules, and the therapeutic response and its conditioning factors should be evaluated at each step before proceeding further.

Exploring Current Concepts and Challenges in the Identification and Management of Early-Stage COPD

“…We know that one of the many differences between asthma and COPD concerns the age of onset, which is earlier in asthma. Consequently, the study of chronic respiratory symptoms in a young patient should begin by evaluating a diagnosis of asthma [ 39 ]. Additionally, the combination of the two diagnoses in a single patient constitutes a challenge for the clinician, especially at younger ages, with direct clinical consequences [ 40 , 41 ].…”

Triple Therapy for COPD: Historical Perspective and Current Controversies

“…It has been described that inhaled drugs often have an individualized response at the patient level, which may lead to a certain degree of unpredictability which qualifies their effectiveness 39,40 . Consequently, a change in molecule could lead to a change in effectiveness, despite the molecule belonging to the same pharmacological group 41 . Therefore, any comparison between open versus closed triple therapies will be affected by whether the comparator groups share the same inhaler and molecules or not.…”