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      Inhaled Corticosteroids Prescribed for COPD Patients with Mild or Moderate Airflow Limitation: Who Warrants a Trial of Withdrawal?

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          Abstract

          COPD patients prescribed inhaled corticosteroids (ICS) outside guidelines should be targeted for ICS withdrawal. Within a primary care population of 209,618 we used a combination of digital search algorithm, individual record review, and clinical review to identify COPD patients suitable for a trial of ICS withdrawal. At most, 39% of COPD patients with mild or moderate airflow limitation prescribed ICS were suitable for withdrawal according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Recurrent exacerbations and reversible airway obstruction were the main reasons for patients’ unsuitability for withdrawal. Identifying COPD patients in whom ICS withdrawal should be considered presents a challenge to primary care clinicians.

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          Most cited references 5

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          Withdrawal of inhaled corticosteroids in COPD: A meta-analysis

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            A proposal for the withdrawal of inhaled corticosteroids in the clinical practice of chronic obstructive pulmonary disease

            According to the current clinical practice guidelines for chronic obstructive pulmonary disease (COPD), the addition of inhaled corticosteroids (ICS) to long-acting β2 agonist therapy is recommended in patients with moderate-to-severe disease and an increased risk of exacerbations. However, ICS are largely overprescribed in clinical practice, and most patients are unlikely to benefit from long-term ICS therapy. Evidence from recent randomized-controlled trials supports the hypothesis that ICS can be safely and effectively discontinued in patients with stable COPD and in whom ICS therapy may not be indicated, without detrimental effects on lung function, health status, or risk of exacerbations. This article summarizes the evidence supporting the discontinuation of ICS therapy, and proposes an algorithm for the implementation of ICS withdrawal in patients with COPD in clinical practice. Given the increased risk of potentially serious adverse effects and complications with ICS therapy (including pneumonia), the use of ICS should be limited to the minority of patients in whom the treatment effects outweigh the risks.
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              Chronic obstructive pulmonary disease hospital admissions and drugs—unexpected positive associations: a retrospective general practice cohort study

              Background: Increased prescribing of inhaled long-acting anti-muscarinic (LAMA) and combined inhaled long-acting β2-agonist and corticosteroid (LABA+ICS) drugs for the treatment of chronic obstructive pulmonary disease (COPD) has led to hopes of reduced hospital admissions from this disease. Aims: To investigate the impact of rising primary care prescribing of LAMA and LABA+ICS drugs on COPD admissions. Methods: This retrospective cohort study of general practice COPD admission and prescribing data between 2007 and 2010 comprised a representative group of 806 English general practices (population 5,264,506). Outcome measures were practice rates of COPD patient admissions and prescription costs of LAMA and LABA+ICS. General practice characteristics were based on the UK quality and outcomes framework. Results: Rates of COPD admissions remained stable from 2001 to 2010. Practice-prescribing volumes of LAMA per practice patient and LABA+ICS per practice patient increased by 61 and 26%, respectively, between 2007 and 2010. Correlation between costs of LAMA and those of LABA+ICS increased year on year, and was the highest in 2010 (Pearson’s r=0.68; 95% confidence interval (CI), 0.64–0.72). Practice COPD admission rates were positively predicted by practice-prescribing volumes of LAMA (2010: B=1.23, 95% CI, 0.61–1.85) and of LABA+ICS (2010: B=0.32, 95% CI, 0.12–0.52) when controlling for practice list size, COPD prevalence and deprivation. Conclusion: The increase in the prescribing of LAMA and LABA+ICS inhalers was not associated with the predicted fall in hospital admission rates for COPD patients. The positive correlation between high practice COPD prescribing and high practice COPD admissions was not explained.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                COPD
                copd
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove
                1176-9106
                1178-2005
                31 December 2019
                2019
                : 14
                : 3063-3066
                Affiliations
                [1 ]Department of Public Health and Primary Care, School of Population Health and Environmental Sciences, King’s College London , London, UK
                [2 ]Department of Asthma Allergy and Respiratory Science, King’s College London , London, UK
                [3 ]Lane Fox Respiratory Unit, Guy’s and St. Thomas’ NHS Foundation Trust and King’s College London , London, UK
                [4 ]Primary Care and Population Medicine, University of Southampton , Southampton, UK
                Author notes
                Correspondence: Timothy H Harries Department of Public Health and Primary Care, School of Population Health and Environmental Sciences, King’s College London 3rd Floor Addison House, Guys Campus, LondonSE1 1UL, UKTel +44 20 7836 5454 Email timothy.harries@kcl.ac.uk
                Article
                238239
                10.2147/COPD.S238239
                6978678
                © 2019 Harries et al.

                This work is published by Dove Medical Press Limited, and licensed under a Creative Commons Attribution License. The full terms of the License are available at http://creativecommons.org/licenses/by/4.0/. The license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                References: 10, Pages: 4
                Funding
                This paper presents independent research funded by the NIHR under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0214-33060). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. THH is in receipt of an NIHR Doctoral Research Fellowship.
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