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      Overuse of inhaled corticosteroids in COPD: five questions for withdrawal in daily practice

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          Abstract

          Evidence and guidelines are becoming increasingly clear about imbalance between the risks and benefits of inhaled corticosteroids (ICSs) in patients with COPD. While selected patients may benefit from ICS-containing regimens, ICSs are often inappropriately prescribed with – according to Belgian market research data – up to 70% of patients in current practice receiving ICSs, usually as a fixed combination with a long-acting β 2-adrenoreceptor agonist. Studies and recommendations support withdrawal of ICSs in a large group of patients with COPD. However, historical habits appear difficult to change even in the light of recent scientific evidence. We have built a collaborative educational platform with chest physicians and primary care physicians to increase awareness and provide guidance and support in this matter.

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          Most cited references 29

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          Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial

          Blood eosinophil counts might predict response to inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) and a history of exacerbations. We used data from the WISDOM trial to assess whether patients with COPD with higher blood eosinophil counts would be more likely to have exacerbations if ICS treatment was withdrawn.
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            Inhaled corticosteroids for stable chronic obstructive pulmonary disease.

            The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD. To determine the efficacy and safety of inhaled corticosteroids in stable patients with COPD, in terms of objective and subjective outcomes. A pre-defined search strategy was used to search the Cochrane Airways Group Specialised Register for relevant literature. Searches are current as of July 2011. We included randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta(2)-agonists and bronchial hyper-responsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. We also analysed data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety. Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials. Fifty-five primary studies with 16,154 participants met the inclusion criteria. Long-term use of ICS (more than six months) did not consistently reduce the rate of decline in forced expiratory volume in one second (FEV(1)) in COPD patients (generic inverse variance analysis: mean difference (MD) 5.80 mL/year with ICS over placebo, 95% confidence interval (CI) -0.28 to 11.88, 2333 participants; pooled means analysis: 6.88 mL/year, 95% CI 1.80 to 11.96, 4823 participants), although one major trial demonstrated a statistically significant difference. There was no statistically significant effect on mortality in COPD patients (odds ratio (OR) 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long-term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: MD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants; pooled means analysis: MD -0.19 exacerbations per patient per year, 95% CI -0.30 to -0.08, 2253 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.65, 95% CI 2.03 to 3.46, 5586 participants) and hoarseness. In the long-term studies, the rate of pneumonia was increased in the ICS group compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.56, 95% CI 1.30 to 1.86, 6235 participants). The long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years. Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life and possibly reduced rate of decline in FEV(1)) against the potential side effects (oropharyngeal candidiasis and hoarseness, and risk of pneumonia).
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              The asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS): opportunities and challenges.

              Some individuals share characteristics of asthma and chronic obstructive pulmonary disease (COPD). The asthma-COPD overlap syndrome (ACOS) has been defined as symptoms of increased variability of airflow in association with an incompletely reversible airflow obstruction. In this review, we present the latest findings in the diagnosis, characterization and management of ACOS.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2018
                05 July 2018
                : 13
                : 2089-2099
                Affiliations
                [1 ]Department of Respiratory Medicine, Centre Hospitalier Universitaire de Liège (CHU) and University of Liège, Liège, Belgium, didier.cataldo@ 123456uliege.be
                [2 ]Department of Respiratory Medicine, Ghent University Hospital, Gent, Belgium
                [3 ]Department of Respiratory Medicine, University Hospitals Saint-Luc, Brussels, Belgium
                [4 ]Department of Respiratory Medicine, University Hospital UCL Namur, Yvoir, Belgium
                [5 ]URPhyM, University of Namur, Namur, Belgium
                [6 ]Department of Respiratory Medicine, University Hospital Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
                [7 ]Department of Respiratory Medicine, University Hospital Vésale, Montigny-le-Tilleul, Belgium
                [8 ]Department of Respiratory Medicine, ZNA Middelheim, Antwerpen, Belgium
                [9 ]Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
                [10 ]Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
                Author notes
                Correspondence: Didier Cataldo, Department of Respiratory Medicine, Centre Hospitalier Universitaire de Liège, University of Liège, Hippocrates Avenue, 13 – Building B23, Third floor, 4000 Liège, Belgium, Tel +32 4 366 2521, Fax +32 4 366 2939, Email didier.cataldo@ 123456uliege.be
                Article
                copd-13-2089
                10.2147/COPD.S164259
                6039066
                © 2018 Cataldo et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Review

                Respiratory medicine

                copd, exacerbation, withdrawal, inhaled steroids, systematic review, education

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