The Effect of Inhaled Corticosteroid Withdrawal on Inflammation and the Airway Microbiome in COPD: The INCOGNITO Trial

Keir, Holly R.; Richardson, Hollian; Veluchamy, Abirami; Lima, D. Alferes de; Hennayake, Chandani Kumari; Cassidy, D.M.; Dicker, Alison; Clarke, Clare; Band, Margaret; Finch, S.M.; Billingham, P.; Crichton, Megan; Bourke, Stephen; Haughney, John; Lipworth, B.J.; Shaw, Debra J.; Chalmers, JD

doi:10.1164/ajrccm-conference.2022.205.1_meetingabstracts.a5567

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“…However, further studies are needed to clarify the effects of ICS on the lung microbiome. Most recently, ICS withdrawal in the INCOGNITO study was associated with potentially beneficial changes in microbiome composition and altered the exacerbation endotype, with a reduction in bacterial-associated exacerbations 99 , 100 . The increased risk of respiratory infections with ICS treatment may be linked with their immunosuppressive effects, including reductions in T-cell, macrophage and neutrophil function in the lung 101 , 102 .…”

Section: Increased Risk Of Adverse Events and Cost Implications Assoc...mentioning

confidence: 99%

Rational use of inhaled corticosteroids for the treatment of COPD

Quint¹,

Ariel²,

Barnes³

2023

npj Prim. Care Respir. Med.

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Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50–80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.

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Section: Increased Risk Of Adverse Events and Cost Implications Assoc...mentioning

confidence: 99%