International Journal of COPD (Sep 2019)
A Framework For Step Down Or Therapeutic Re-Organization For Withdrawal Of Inhaled Corticosteroids In Selected Patients With COPD: A Proposal For COPD Management
Abstract
Claudio Micheletto,1 Fulvio Braido,2 Marco Contoli,3 Fabiano Di Marco,4 Pierachille Santus5 1Respiratory Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; 2Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCS San Martino, Genoa, Italy; 3Department of Medical Sciences, University of Ferrara, Ferrara, Italy; 4Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy; 5Department of Health Sciences, Università degli Studi di Milano,Pulmonary Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli, Milan, ItalyCorrespondence: Claudio MichelettoRespiratory Unit, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, Verona 37122, ItalyTel +39 045 8122248Email [email protected]: 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, exacerbation, inhaled corticosteroids, LABA, LAMA, deprescribing
