![]() ![]() In this context, the WISDOM study published recently 10 concludes that in patients with severe COPD receiving tiotropium (LAMA) plus salmeterol (LABA) plus fluticasone propionate (ICS), the gradual discontinuation of the latter until complete suppression does not increase significantly the risk of moderate or severe ECOPD, albeit there was a significantly greater decline in lung function in those patients in whom ICS was withdrawn. 1 Not surprisingly, therefore, there has been interest in studying the effect of ICS withdrawal in COPD. Second, likely as a consequence of ICS being “inherited” from asthma, as discussed above, there is ICS over prescription in COPD, 4 particularly in patients classified in GOLD groups A or B, where ICS should not be theoretically prescribed. 1 Yet, as it is often the case, the devil is in the details since: (1) this study lasted for 26 weeks only, probably a period of time that is too short to assess with certainty the effect of any treatment on the incidence of ECOPD (2) the study included patients without a history of previous ECOPD, 7 when it is well established that the best predictor of future ECOPD is a previous history of ECOPD 9 and, (3) patients who had a moderate-to-severe ECOPD were withdrawn from the study. 7 This observation may indicate that a LABA-LAMA combination has a similar effect on ECOPD than a LABA-ICS combination and, remember, according to GOLD, ICS are indicated in COPD to reduce the risk of future exacerbations. Interestingly, authors did not find significant differences in the incidence of “adverse events” (including ECOPD). 4 For instance, the recent ILLUMINATE study 7 showed, not surprisingly, that lung function improvement was significantly better in patients who received a fixed combination of indacaterol (LABA) and glycopirronium (LAMA) than in those who received a fixed combination of salmeterol (LABA) and fluticasone propionate (ICS): two bronchodilators bronchodilate more than one!. 7, 8 To my mind, the availability of these new therapeutic alternatives will inevitably force the academic community to carefully re-consider the position ICS within the therapeutic armamentarium of COPD. ![]() 6 Even more recently, new fixed combination of LABA-LAMA's have been also developed for COPD and can now be prescribed in many markets. 5 It is only recently that new long-acting bronchodilators have been developed specifically for the treatment of COPD (not asthma), as best exemplified by tiotropium (a long acting anti-muscarininc agent LAMA). 4 This Editorial briefly discusses what, in my opinion, are some of the main arguments that fuel this debate.įirst, drug therapy in COPD was actually “inherited” from asthma and basically consisted in the use of long-acting β2 agonists (LABA) and ICS. Despite this, apparently straightforward situation, there is a lively debate on where ICS should be positioned in the treatment of COPD. 2 On the contrary, ICS should never be used in mono-therapy (i.e., alone) in COPD patients 1 (an important difference vs. 1 More recently, ICS have also been recommended for the treatment of the so-called Asthma-COPD overlap syndrome (ACOS). ![]() 1 According to this document, ICS are indicated in COPD patients with severe or very severe airflow limitation (FEV1 < 50% of predicted) and/or frequent exacerbations (ECOPD) that are not adequately controlled by long-acting bronchodilators (Evidence A) because they reduce the risk of future episodes of ECOPD. The indications (and contraindications) of treatment with inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) are well established in the latest iteration of the Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD) document. ![]()
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |