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A Framework For Step Down Or Therapeutic Re-Organization For Withdrawal Of Inhaled Corticosteroids In Selected Patients With COPD: A Proposal For COPD Management

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A Framework For Step Down Or Therapeutic Re-Organization For Withdrawal Of Inhaled Corticosteroids In Selected Patients With COPD: A Proposal For COPD Management

Claudio Micheletto et al. Int J Chron Obstruct Pulmon Dis.

Abstract

While chronic obstructive pulmonary disease (COPD) continues to be a major cause of morbidity and mortality, pharmacological therapy has a definite benefit on symptoms as well as the frequency and severity of exacerbations, and general health. The most recent Global Initiative for Obstructive Lung Disease (GOLD) guidelines recommend triple therapy (long-acting beta2 agonists [LABA] + long-acting muscarinic antagonists [LAMA] + inhaled corticosteroids [ICS]) only for patients with exacerbations, elevated eosinophils, and without control using a LABA/LAMA or ICS/LABA combination. Long-term monotherapy with ICS is not currently recommended, but may be considered in association with LABAs in patients with a history of exacerbations and elevated eosinophils in spite of appropriate treatment with long-acting bronchodilators. However, long-term use of ICS in combination therapy has been associated with adverse effects, even if widely used in routine management for decades. The available evidence suggests that ICS can be rationally discontinued in patients with stable disease and is not likely to have unfavorable effects on lung function, overall health, or be associated with a greater risk of exacerbations. Indeed, it is widely accepted that ICS therapy should be limited to a small proportion of patients after careful assessment of the individual risk-benefit profile. Unfortunately, however, there are no international recommendations that provide specific guidance or a protocol for withdrawal of ICS. Herein, the available evidence on the use of ICS is reviewed and an easy to use tool is proposed that can provide clinicians with a simple management scheme to guide the most appropriate therapy for management of COPD and use of ICS. In management of COPD, a highly personalized approach is advocated so that the most appropriate therapy for each individual patient can be selected.

Keywords: COPD; LABA; LAMA; deprescribing; exacerbation; inhaled corticosteroids.

Conflict of interest statement

Claudio Micheletto reports personal fees from AstraZeneca, GSK, Menarini, Guidotti, Berlin Chemie, Novartis, Zambom, and Boehringer Ingelheim, outside the submitted work. Marco Contoli reports grants and personal fees from AstraZeneca and Chiesi, and personal fees from ALK-Abello, Novartis, Zambon, GlaxoSmithKline, and Boehringer Ingelheim, outside the submitted work. Fabiano Di Marco reports grants, personal fees, and non-financial support from AstraZeneca, Boehringer Ingelheim, Chiesi, Novartis, Menarini, Malesci, Guidotti, TEVA, and Zambon, outside the submitted work. Pierachille Santus reports grants and personal fees from Boehringer Ingelheim and AstraZeneca, grants from Chiesi Farmaceutici and Almirall, and personal fees from ALK-Abello, Berlin Chemie, GSK, Sanofi, and Zambon Italia, during the conduct of the study. The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
GOLD 2019 algorithms for initial pharmacological treatment of COPD. aConsider if highly symptomatic (e.g. CAT>20). bConsider if eosinophils > 300 cells/μL. Note: Reprinted with permission from: Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 Report. Available from: https://goldcopd.org/gold-reports/. Accessed September 10, 2019. ©2019 Global Initiative for Chronic Obstructive Lung Disease. Available from: www.goldcopd.org.
Figure 2
Figure 2
Decisional tool to guide the most appropriate management of COPD. Stable disease is defined as no acute exacerbation of symptoms in the past year.

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