Stufentherapie der COPD

2019 ◽  
Vol 144 (01) ◽  
pp. 15-20
Author(s):  
Henrik Watz ◽  
Anne Kirsten ◽  
Timm Greulich
Keyword(s):  
Inhaled Corticosteroids ◽  
Exercise Intolerance ◽  
Pharmacologic Therapy ◽  
Chronic Obstructive ◽  
Blood Eosinophil ◽  
Obstructive Pulmonary Disease ◽  
Dual Bronchodilation ◽  
Related Quality ◽  
Health Related ◽  
Long Acting

AbstractThe goal of pharmacologic therapy of stable chronic obstructive pulmonary disease (COPD) is to reduce symptoms, improve exercise intolerance and health-related quality of life, and to reduce exacerbations. Inhaled long-acting β2-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are equally effective for the symptomatic management of COPD. However, LAMAs are more effective than LABAs in the reduction of exacerbations. In patients with symptomatic COPD pharmacologic therapy is usually escalated using the fixed combination of LAMAs and LABAs (dual bronchodilation), which is also superior to LAMA monotherapy in the prevention of exacerbations. Adding inhaled corticosteroids (ICS) to LABA and LAMA (triple therapy) for a prevention of exacerbations results in a further reduction of exacerbations, especially in those patients with higher blood eosinophil counts. Non-pharmacologic management of COPD patients includes smoking cessation programs, vaccination, pulmonary rehabilitation, and strategies to improve or maintain their physical activity.

scholarly journals Combination of ICSs and LABAs Should Be Used in the Management of Patients with COPD — The Con Argument

2004 ◽  
Vol 11 (3) ◽  
pp. 224-226
Author(s):  
Jeremy Road
Keyword(s):  
Inhaled Corticosteroids ◽  
Forced Expiratory Volume ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Randomized Controlled ◽  
The Past ◽  
Related Quality ◽  
Health Related ◽  
Long Acting

The management of patients with symptomatic chronic obstructive pulmonary disease (COPD) has become more clear in the past several years. New medications have been developed and their efficacy has been evaluated using important outcomes in addition to forced expiratory volume in 1 s (FEV1), such as health-related quality of life (HRQL), frequency of exacerbations and dyspnea scores. I will review five welldesigned, randomized, controlled trials that have advanced our knowledge about the use of inhaled corticosteroids (ICSs), long-acting beta2-agonists (LABAs) and their combination.

scholarly journals Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline

2020 ◽  
Vol 55 (6) ◽  
pp. 2000351 ◽  
Author(s):  
James D. Chalmers ◽  
Irena F. Laska ◽  
Frits M.E. Franssen ◽  
Wim Janssens ◽  
Ian Pavord ◽  
...  
Keyword(s):  
Inhaled Corticosteroids ◽  
Evidence Synthesis ◽  
Chronic Obstructive ◽  
Blood Eosinophil ◽  
European Respiratory Society ◽  
Obstructive Pulmonary Disease ◽  
Strong Recommendation ◽  
Assessment Development ◽  
Evaluation Approach ◽  
Long Acting

Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL−1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.

scholarly journals Individual trajectory-based care for COPD: getting closer, but not there yet

2021 ◽  
pp. 00451-2021
Author(s):  
Nicolas Roche ◽  
Philippe Devillier ◽  
Patrick Berger ◽  
Arnaud Bourdin ◽  
Daniel Dusser ◽  
...  
Keyword(s):  
Inhaled Corticosteroids ◽  
Clinical Symptoms ◽  
Pharmacological Therapy ◽  
Response To Therapy ◽  
Treatment Preference ◽  
Chronic Obstructive ◽  
Blood Eosinophil ◽  
Close Monitoring ◽  
Obstructive Pulmonary Disease ◽  
Long Acting

Chronic obstructive pulmonary disease (COPD) is a main cause of death due to interplaying factors, including comorbidities that interfere with symptoms and response to therapy. It is now admitted that COPD management should be based on clinical symptoms and health status, and should consider the heterogeneity of patients’ phenotypes and treatable traits. This precision medicine approach involves a regular assessment of the patient's status and of expected benefits and risks of therapy. The cornerstone of COPD pharmacological therapy is inhaled long-acting bronchodilation. In patients with persistent or worsened symptoms, factors likely to interfere with treatment efficacy include the patient's non-adherence to therapy, treatment preference, inhaler misuse and/or comorbidities, which should be systematically sought before escalation is considered. Several comorbidities are known to impact symptoms, activity and lung function in vicious circles. The possible long-term risks of inhaled corticosteroids contrasting with their over-prescription in COPD patients justify the regular assessment of their benefits and risks, and de-escalation under close monitoring after a sufficient period of stability is to be considered. While commonly used in clinical trials, the relevance of routine blood eosinophil counts to guide therapy adjustment is not fully clarified. Patients’ characteristics, which define phenotypes and treatable traits and thus guide therapy, often change during life, forming the basis of the concept of clinical trajectory. The application of individual trajectory-based management of COPD in clinical practice therefore implies that the benefit:risk ratio is regularly reviewed according to the evolution of the patient's traits over time to allow optimized therapy adjustments.

scholarly journals Heterogeneity within and between physician-diagnosed asthma and/or COPD: NOVELTY cohort

2021 ◽  
pp. 2003927
Author(s):  
Helen K Reddel ◽  
Jørgen Vestbo ◽  
Alvar Agustí ◽  
Gary P Anderson ◽  
Aruna T Bansal ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Treatment Options ◽  
Chronic Obstructive ◽  
Blood Eosinophil ◽  
Obstructive Pulmonary Disease ◽  
Ordinal Logistic Regression Analysis ◽  
Related Quality ◽  
Health Related ◽  
Substantial Heterogeneity

BackgroundStudies of asthma and chronic obstructive pulmonary disease (COPD) typically focus on these diagnoses separately, limiting understanding of disease mechanisms and treatment options. NOVELTY is a global, 3-year, prospective observational study of patients with asthma and/or COPD from real-world clinical practice. We investigated heterogeneity and overlap by diagnosis and severity in this cohort.MethodsPatients with physician-assigned asthma, COPD or both (asthma+COPD) were enrolled, stratified by diagnosis and severity. Baseline characteristics were reported descriptively by physician-assigned diagnosis and/or severity. Factors associated with physician-assessed severity were evaluated using ordinal logistic regression analysis.ResultsOf 11 243 patients, 5940 (52.8%) had physician-assigned asthma, 1396 (12.4%) had asthma+COPD and 3907 (34.8%) had COPD; almost half were from primary care. Symptoms, health-related quality of life and spirometry showed substantial heterogeneity and overlap between asthma, asthma+COPD and COPD, with 23%, 62% and 64% of patients, respectively, having post-bronchodilator FEV1/FVC <lower limit of normal.Symptoms and exacerbations increased with greater physician-assessed severity, and were higher in asthma+COPD, but 24.3% with mild asthma and 20.4% with mild COPD had experienced ≥1 exacerbation in the past 12 months. Medication records suggested both under-treatment and over-treatment relative to severity. Blood eosinophil counts varied little across diagnosis/severity groups, but blood neutrophil counts increased with severity across all diagnoses.ConclusionThis analysis demonstrates marked heterogeneity within, and overlap between, physician-assigned diagnosis and severity groups in patients with asthma and/or COPD. Current diagnostic and severity classifications in clinical practice poorly differentiate between clinical phenotypes that may have specific risks and treatment implications.

scholarly journals HEALTH-RELATED QUALITY OF LIFE ASSESSMENT USING SINGLE-INHALER DUAL VERSUS TRIPLE THERAPY IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENTS

2020 ◽  
pp. 47-52
Author(s):  
TALATH FATIMA ◽  
ANNIE FATIMA SADAF ◽  
SYED AAMIR ALI ◽  
JUNAID SIDDIQUI ◽  
MIRZA MISBA ALI BAIG ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Triple Therapy ◽  
Dual Therapy ◽  
Chronic Obstructive ◽  
Health Related Quality ◽  
Obstructive Pulmonary Disease ◽  
Related Quality ◽  
Health Related ◽  
Long Acting

Objectives: The study compared triple therapy (inhaled corticosteroids/long-acting beta2-agonists [LABA]/long-acting muscarinic antagonists [LAMA]) versus dual therapy [LABA/LAMA] in improving lung function and health-related quality of life (HRQoL) of patients with chronic obstructive pulmonary disease (COPD). Methods: This prospective and observational study compared 12 weeks of triple therapy (Formoterol – 6 mcg/Ciclesonide – 200 mcg/Tiotropium – 9 mcg) versus dual therapy (Formoterol – 6 mcg/Tiotropium – 9 mcg) in COPD patients. The primary objective included HRQoL as measured by improvement (decrease) from baseline in St. George respiratory questionnaire (SGRQ) score and COPD assessment test (CAT) scores. Coprimary endpoint included the change from baseline in forced expiratory volume in 1 second (FEV1). Results: After 12 weeks of treatment, triple therapy (n=30) and dual therapy (30), mean improvement (decrease) from baseline in SGRQ scores was −21.06 (95% CI, −24.92–−17.20) and −5.89571 (95% CI, −7.71–−4.07), respectively, and mean improvement (decrease) from baseline in CAT scores was −2.83 (95% CI, −3.73–−1.94] and −1.8 (95% CI, −2.25–−1.35), respectively. The mean change from baseline in FEV1% predicted was 3.09 (95% CI, 2.18–4.00) and 1.69 (95% CI, 1.43–1.97) for triple and dual therapy, respectively. For all the endpoints, the between-group mean differences were statistically significant (p<0.001). Conclusion: Triple therapy (Formoterol – 6 mcg/Ciclesonide – 200 mcg/Tiotropium – 9 mcg) can provide improvements in lung function and quality of life over dual therapy (Formoterol – 6 mcg/Tiotropium – 9 mcg) in patients with moderate to severe COPD. Future studies should focus on which drug combination of triple therapy is more effective and cost-effective than other possible triple therapy drug combinations.

Narrative Literature Review Guided Approach of Inhaled Corticosteroid de-escalation in Chronic Obstructive Pulmonary Disease

2021 ◽  
pp. 089719002110537
Author(s):  
Anamarie Tomaich ◽  
Shawnee Klatt ◽  
Michael W. Nagy
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Pulmonary Disease ◽  
Inhaled Corticosteroids ◽  
Chronic Obstructive Lung Disease ◽  
Chronic Obstructive ◽  
Blood Eosinophil ◽  
Inhaled Corticosteroid ◽  
Obstructive Pulmonary Disease ◽  
Copd Patients ◽  
Long Acting

Objective To review the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report recommendations and create an algorithm to assist clinicians in determining which chronic obstructive pulmonary disease (COPD) patients qualify for inhaled corticosteroid (ICS) de-escalation. Data Sources: A literature search of MEDLINE/PubMed from 2002 to August 2021 was conducted using the search terms inhaled corticosteroids, chronic obstructive pulmonary disease, and de-escalation and review of the reference lists of identified articles for pertinent citations. Study Selection and Data Extraction Relevant studies and articles were included if they focused on the utilization of ICS in COPD. Data Synthesis The 2020 GOLD report only recommends triple therapy with ICS, long acting beta agonists, and long acting muscarinic antagonists for patients with frequent exacerbations, frequent hospitalizations, or elevated blood eosinophil counts. Despite this clear framework, patients are prescribed ICS without these characteristics. Available evidence suggests that these patients can be de-escalated from ICS therapy without concern for worsening lung function or exacerbations. Relevance to Patient Care and Clinical Practice: Patients with COPD may be experiencing more risk than benefit on ICS therapy. Clinicians should be knowledgeable on how to evaluate patient therapy for appropriateness and know how to safely deprescribe ICS given their limited efficacy in many COPD patients. Conclusion There remains no specific guidance on how to de-escalate patients off an ICS when the therapy is not indicated. Use of clinical evidence with stepwise algorithms can be models to approach de-escalation of ICS in patients with COPD.

scholarly journals Triple Therapy Versus Dual Bronchodilation and Inhaled Corticosteroids/Long-Acting β-Agonists in COPD: Accumulating Evidence from Network Meta-Analyses

2019 ◽  
Vol 5 (2) ◽  
pp. 117-126 ◽  
Author(s):  
Mario Cazzola ◽  
Luigino Calzetta ◽  
Paola Rogliani ◽  
Maria Gabriella Matera
Keyword(s):  
Triple Therapy ◽  
Clinical Benefit ◽  
Inhaled Corticosteroids ◽  
Daily Practice ◽  
Chronic Obstructive ◽  
Blood Eosinophil ◽  
Dual Bronchodilation ◽  
Long Acting ◽  
Meta Analyses

Abstract Guidelines are mainly based on evidence of well-designed randomized controlled trials (RCTs), but there are limitations to the transferability of conclusions of RCTs to usual care mainly because the patients enrolled in RCTs are selected and not representative of the population encountered in daily practice; moreover, the research environment is substantially different from that of the real world. Because of the scarcity of data generated in large unselected populations in everyday clinical practice, the possibility of using meta-analyses can be considered. Recently, several meta-analyses have attempted to clarify the role of triple therapy containing a long-acting β-agonist (LABA), a long-acting muscarinic antagonist (LAMA) and an inhaled corticosteroid (ICS) delivered from a single inhaler in chronic obstructive pulmonary disease (COPD), also considering that there is a big difference in the use of triple therapy between what is recommended by COPD guidelines or strategies and the prescriptive behaviour of clinicians. Taking into account the results of the most recent meta-analyses, we believe that triple therapy provides modest clinical benefit in the general COPD population, but in patients on LABA/LAMA combination therapy, who still experience acute exacerbations of COPD (AECOPDs) and have blood eosinophil counts ≥ 300 cells·μl−1, it is of clinical relevance. On the contrary, adding a LAMA to an ICS/LABA combination elicits relevant clinical benefit in the general COPD population, supporting the role of dual bronchodilation therapy for the treatment of COPD. The quantitative synthesis of the currently available clinical evidence seems to suggest that, in patients with COPD already on ICS/LABA combination, the therapy can be improved without an increase of cardiovascular severe adverse events (SAEs) when a LAMA is added to the combination.

scholarly journals Inhaled therapies for chronic obstructive pulmonary disease: a systematic review and meta-analysis

BMJ Open ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. e036455
Author(s):  
Eleanor L Axson ◽  
Adam Lewis ◽  
James Potts ◽  
Marie Pang ◽  
Scott Dickinson ◽  
...  
Keyword(s):  
Adverse Events ◽  
Observational Studies ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Related Quality ◽  
Health Related ◽  
Long Acting ◽  
Meta Analyses

ObjectivesTo integrate evidence from randomised controlled trials (RCTs) and observational studies on the efficacy of inhaled treatments for chronic obstructive pulmonary disease using network meta-analyses.MethodsSystematic searches MEDLINE and Embase based on predetermined criteria. Network meta-analyses of RCTs investigated efficacy on exacerbations (long-term: ≥20 weeks of treatment; short-term: <20 weeks), lung function (≥12 weeks), health-related quality of life, mortality and adverse events. Qualitative comparisons of efficacies between RCTs and observational studies.Results212 RCTs and 19 observational studies were included. Compared with combined long-acting beta-adrenoceptor agonists and long-acting muscarinic antagonists (LABA+LAMA), triple therapy (LABA+LAMA+inhaled corticosteroid) was significantly more effective at reducing exacerbations (long-term 0.85 (95% CI: 0.78 to 0.94; short-term 0.67 (95% CI: 0.49 to 0.92)) and mortality (0.72 (95% CI: 0.59 to 0.89)) but was also associated with increased pneumonia (1.35 (95% CI: 1.10 to 1.67)). No differences in lung function (0.02 (95% CI: −0.10 to 0.14)), health-related quality of life (−1.12 (95% CI: −3.83 to 1.59)) or other adverse events (1.02 (95% CI: 0.96 to 1.08)) were found. Most of the observational evidence trended in the same direction as pooled RCT data.ConclusionFurther evidence, especially pragmatic trials, are needed to fully understand the characteristics of patient subgroups who may benefit from triple therapy and for those whom the extra risk of adverse events, such as pneumonia, may outweigh any benefits.PROSPERO registration numberCRD42018088013.

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