What to use INSTEAD of inhaled corticosteroids in COPD?

Abstract

@ERSpublicationsThe way we use ICS in #COPD should change if we are to offer the safest and most effective treatment to our patients http://ow.ly/Czukb Inhaled corticosteroids (ICS) have had an important impact on the management of chronic obstructive pulmonary disease (COPD). When combined with an inhaled long-acting b-agonist (LABA), they improve lung function more than is the case with the LABA alone, improve health status and reduce the number of exacerbations patients experience [1]. There are data to suggest that they modify the decline in lung function and improve survival but these effects remain more controversial [1,2]. There have always been concerns about the risks of developing osteoporosis or cataracts and even diabetes in COPD patients who use ICS drugs, although randomised controlled studies suggest that the impact of such changes are small in patients with more severe COPD [3]. However, there is now consistent evidence from randomised controlled trials that patients using fluticasone-based corticosteroids are more likely to develop pneumonia [4,5]. The clinical significance of these events remains less certain [6,7] as does the generalised ability of these findings to all ICS [8]. Nonetheless, concerns about the balance of the risks and benefits of ICSbased treatments has led to renewed interest in defining patients who could be managed as well with other therapies.One way to establish whether ICS treatment should be continued is to stop it and see what happens. Early observational studies and randomised control trials suggested that acute withdrawal of ICS from the treatment regimen of COPD patients precipitated an exacerbation and/or increased symptoms [9,10]. Recently, two relatively large studies have examined the effects of withdrawing ICS in rather different populations of patients who were clinically stable at the time of study entry. The larger of these, the Withdrawal of Inhaled Steroids During Optimised Management (WISDOM) trial, screened 3426 patients, of whom 2488 were randomised [11]. All the patients were given an ICS, a LABA and the long-acting antimuscarinic agent (LAMA) tiotropium for 6 weeks then randomised either to continue these drugs or to reduce slowly the dose of the ICS over 3 months, after which time they were managed on the LABA and LAMA alone. To the surprise of everyone, not least the investigators, there was no difference in the exacerbation rate during the period of ICS withdrawal, nor was there a difference in the overall exacerbation rate for moderate and severe events over the year as a whole. There was a suggestion that the number of severe exacerbations increased transiently, just after the ICS was completely withdrawn, and a difference of ,50 mL in lung function emerged between the two treatments, in keeping with the known effects if ICS on forced expiratory volume in 1 s (FEV1) [1]. Neither the prior exacerbation history nor the previous treatment used by the patient influenced these conclusions.With hindsight, it would have been better to extend the follow-...

Salmeterol/fluticasone combination instead of indacaterol orvice-versa?

“…Clearly, any history of either asthma or like-asthma symptoms was in the exclusion criteria [1]. The INSTEAD randomised trial confirms the results of a recent real-life study on >800 moderate COPD patients [4], and supports the current management guidance on moderate COPD without history of exacerbations [3]. Were the patients in INSTEAD exacerbation-free in the previous year because they were treated with ICS?…”

“…We believe that INSTEAD data provides a significant contribution to the debate on the appropriate use of ICS in COPD patients [3,14]. @ERSpublications This study shows that inhaled corticosteroids are not needed in COPD patients at low risk of exacerbations http://ow.ly/IkmDF…”

“…The conclusion of the study, which is difficult to challenge, was that the population of COPD patients in the INSTEAD study does not need ICS, and that ICS can be safely withdrawn, if that treatment was initiated. In fact, according to COPD management guidance, these patients should not receive ICS in addition to their maintenance treatment with long-acting bronchodilators [3]. The results of our study should be evaluated for the recruited population and not for patients with either more severe COPD or frequent exacerbations, or both.…”

Tiotropium Bromide in Chronic Obstructive Pulmonary Disease and Bronchial Asthma

“…The results suggest that in this subgroup of patients, a once daily LABA produces similar changes in lung function to a twice daily LABA plus IGS. There were no statistically significant differences in the exacerbation rate, dyspnea index, use of rescue medication or number of serious adverse events [ 49 , 50 ].…”

Knowing when to stop: inhaled corticosteroids and COPD

“…The randomised controlled INSTEAD study took this a stage further and found no increased risk of exacerbation in patients without prior exacerbations who had less severe lung function impairment when a once-daily long-acting beta-agonist was used as maintenance therapy [18]. This study has been reviewed in detail previously [19]. Finally the WISDOM study considered an even more challenging patient group who had had previous exacerbations and were given two bronchodilators and ICS therapy before the ICS was randomly withdrawn over 3 months.…”