Withdrawal of fluticasone propionate from combined salmeterol/fluticasone treatment in patients with COPD causes immediate and sustained disease deterioration: A randomised controlled trial

Wouters, E.F.M.; Postma, D.S.; Fokkens, Bernardina T.; Hop, Wcj; Prins, J. B.; Kuipers, AF; Pasma, Henk; Hensing, C.A.J.; Creutzberg, E.C.

doi:10.1016/j.rmedu.2005.09.024

Cited by 81 publications

(118 citation statements)

References 13 publications

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“…Most studies indicate that the greatest benefit in terms of exacerbations appears to be in those with the most advanced COPD, as measured by the baseline FEV 1 [160][161][162]. Withdrawal studies also led to an increase in the rate of mild exacerbations and symptoms, and a decrease in health status, with decreases in FEV 1 [161,163,164].…”

Section: Effect Of Ics Alonementioning

confidence: 99%

Inhaled corticosteroids as combination therapy with β-adrenergic agonists in airways disease: present and future

Chung

Caramori

Adcock

2009

Eur J Clin Pharmacol

123

106

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International audienceInhaled corticosteroid (ICS) therapy in combination with long-acting β-adrenergic agonists represents the most important treatment for chronic airways diseases such as asthma and chronic obstructive pulmonary disease (COPD). ICS therapy forms the basis for treatment of asthma of all severities, improving asthma control, lung function and preventing exacerbations of disease. Use of ICS has also been established in the treatment of COPD, particularly symptomatic patients, who experience useful gains in quality of life, likely from an improvement in symptoms such as breathlessness and in reduction in exacerbations, and an attenuation of the yearly rate of deterioration in lung function. The addition of long-acting β-agonist (LABA) therapy with ICS increases the efficacy of ICS effects in moderate-to-severe asthma. Thus, a 800 μg daily dose of the ICS budesonide reduced severe exacerbation rates by 49% compared to a low dose of 200 μg daily, and addition of the LABA formoterol to budesonide (800 μg) led to a 63% reduction. In COPD, the effects of ICS are less prominent but there are beneficial effects on the decline in FEV and the rate of exacerbations. A reduction in the rate of decline in FEV of 16 ml/year with a 25% reduction in exacerbation rate has been reported with the salmeterol and fluticasone combination. A non-significant 17.5% reduction in all-cause mortality rate with ICS and LABA is reported. Chronic inflammation is a feature of both asthma and COPD, although there are site and characteristic differences. ICS targets this inflammation although this effect of ICS is less effective in patients with severe asthma and with COPD; however, addition of LABA may potentiate the anti-inflammatory effects of ICS. An important consideration is the presence of corticosteroid insensitivity in these patients. Currently available ICS have variably potent binding activities to specific glucocorticoid receptors, leading to inhibition of gene expression by either binding to DNA and inducing anti-inflammatory genes or by repressing the induction of pro-inflammatory mediators. Local side effects of ICS include oral candidiasis, hoarseness and dysphonia, while systemic side effects, such as easy bruising and reduction in growth velocity or bone mineral densitometry, are usually restricted to doses above maximally recommended doses. Use of LABA alone in patients with asthma increases the risk of asthma-related events including deaths, but this is less observed with the combination of ICS and LABA. Therefore, use of LABA alone is not recommended for asthma therapy. Future progress in ICS development will be characterised by the introduction of ICS with greater efficacy with a limited side-effect profile, and by longer-acting ICS that can be used in combination with once-daily LABAs. Other agents that could improve the efficacy of corticosteroids or reverse corticosteroid insensitivity may be added to ICS. ICS in combination with LABAs will continue to remain the main focus of treatment of airways diseases

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Section: Effect Of Ics Alonementioning

confidence: 99%

Inhaled corticosteroids as combination therapy with β-adrenergic agonists in airways disease: present and future

Chung

Caramori

Adcock

2009

Eur J Clin Pharmacol

123

106

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“…This again suggests a need for improvement in primary-care education. Despite this, the present authors have been reluctant to suggest withdrawal of inhaled steroids in light of recent publications highlighting clinical deterioration after withdrawal [19][20][21].…”

Section: Discussionmentioning

confidence: 85%

Effect of Primary-Care Spirometry on the Diagnosis and Management of Copd

Roitman¹,

Kalra²

2007

Journal of Cardiopulmonary Rehabilitation and Prevention

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Primary-care spirometry has been promoted as a method of facilitating accurate diagnosis of chronic obstructive pulmonary disease (COPD). The present study examined whether improving rates of diagnosis lead to improvements in pharmacological and nonpharmacological management.From 1999 to 2003, the current authors provided an open-access spirometry and reversibility service to a local primary-care area, to which 1,508 subjects were referred. A total of 797 (53%) had pre-bronchodilator airflow obstruction (AFO). Of the subjects who underwent reversibility testing, 19.3% were no longer obstructed post-bronchodilator. The results and records of a subgroup of 235 subjects with post-bronchodilator AFO were examined.Of the 235 subjects, 130 received a new diagnosis, most commonly COPD. The patients with COPD were significantly undertreated before spirometry and testing led to a significant increase in the use of anticholinergics (37 versus 18%), long-acting b-agonists (25 versus 8%) and inhaled steroids (71 versus 52%). More than three quarters of smokers received smoking cessation advice but very few were referred for pulmonary rehabilitation.In conclusion, primary-care spirometry not only increases rates of chronic obstructive pulmonary disease diagnosis, but it also leads to improvements in chronic obstructive pulmonary disease treatment. The use of bronchodilator reversibility testing in this setting may be important to avoid misdiagnosis.

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“…Studies show pre-dose FEV 1 is improved by 13-17% over baseline by LABA/ICS treatment and can significantly increase pre-dose and post-dose FEV 1 compared with ICS monotherapy (Table 1) [29,[37][38][39]41]. In patients taking LABA/ICS combination therapy, the withdrawal of ICS therapy is associated with a significant, acute, and persistent deterioration in lung function [44].…”

Section: Improvements In Lung Function With Laba/ics Therapymentioning

confidence: 99%

“…Significant improvements were consistently seen within one week of initiating treatment and maintained until the study end. In patients taking LABA/ICS combination therapy, the withdrawal of ICS therapy is associated with a significant, acute and persistent deterioration in dyspnoea [44]. In addition, combination LABA/ICS therapy produces a significantly greater improvement in the transition dyspnoea index (TDI) in patients treated with an anti-cholinergic/shortacting beta agonist combination (Combivent) [45,46].…”

Section: O P Y R Ig H T G E N E R a L P R A C T Ic E A Ir W A Y S Gmentioning

confidence: 99%

“…the withdrawal of ICS therapy is associated with an increase in mild exacerbations [44]. These reductions in exacerbation rates are likely to be related to the severity of disease and the frequency of exacerbations in individual patients; indeed, it was noted in one study that patients with an FEV 1 <50% predicted had more than double the time to a first exacerbation [38].…”

Section: O P Y R Ig H T G E N E R a L P R A C T Ic E A Ir W A Y S Gmentioning

confidence: 99%

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Effective management of COPD in primary care — the role of long-acting beta agonist/inhaled corticosteroid combination therapy

Schayck

Reid

2006

Primary Care Respiratory Journal

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Summary Chronic obstructive pulmonary disease (COPD) is the internationally preferred term for chronic, progressive lung disorders which are characterised by airflow limitation that is not fully reversible. The symptoms of COPD -including breathlessness, cough, excessive sputum production and reduced muscle tone and muscle wasting -reflect the complex pathophysiology of the disease. In order to address these symptoms, treatment regimens should take into account the multiple components that contribute to COPD. Clinical evidence has emerged indicating that, especially in patients with severe COPD, long-acting beta 2 -agonists (LABAs) and inhaled corticosteroids (ICS) result in improvements in symptoms, reduce the frequency and severity of exacerbations, and improve health-related quality of life. This review evaluates the clinical evidence for the potential of LABA/ICS treatment to address the symptoms of COPD and whether combination therapy of this nature adds significant benefit to patients.

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Withdrawal of fluticasone propionate from combined salmeterol/fluticasone treatment in patients with COPD causes immediate and sustained disease deterioration: A randomised controlled trial

Cited by 81 publications

References 13 publications

Inhaled corticosteroids as combination therapy with β-adrenergic agonists in airways disease: present and future

Inhaled corticosteroids as combination therapy with β-adrenergic agonists in airways disease: present and future

Effect of Primary-Care Spirometry on the Diagnosis and Management of Copd

Effective management of COPD in primary care — the role of long-acting beta agonist/inhaled corticosteroid combination therapy

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