Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial

Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a serious illness that affects over 5% of the adult population. It is one of the few conditions for which the mortality and morbidity are still increasing. Experts expect COPD to become the third leading cause of death and the fifth leading cause of disability worldwide by the year 2020. Thus far, the only treatments that have been shown to make a difference to survival are smoking cessation and the use of oxygen supplements for those who are hypoxaemic at rest. The use of inhaled corticosteroids as monotherapy or in combination with a long-acting beta2-adrenoceptor agonist for COPD is controversial. Experimental data indicate that the inflammatory process in COPD may be resistant to the anti-inflammatory effects of corticosteroids. However, several large clinical studies have shown that inhaled corticosteroids in relatively high doses (e.g. budesonide 800 microg/day or fluticasone propionate 1 mg/day) reduce exacerbations by 20-30% and improve the health status of COPD patients by a similar amount compared with placebo. Withdrawal of inhaled corticosteroids may increase clinical exacerbation rates by 50% in COPD patients and by 2-fold in those with severe disease. Combined therapy with inhaled corticosteroids and long-acting beta2-adrenoceptor agonists may be superior to individual component therapy in reducing exacerbations. However, these medications must be used cautiously, as they have been associated with certain adverse effects. Inhaled corticosteroids, for instance, increase the risk for dysphonia and oral thrush by 2- to 3-fold. Skin bruising is also more common in users than in non-users of inhaled corticosteroids. On balance, for those with moderate-to-severe COPD and those who experience frequent exacerbations, judicious use of inhaled corticosteroids alone or in combination with long-acting beta2-adrenoceptor agonists appears reasonable.

Skin manifestations of inhaled corticosteroids in COPD patients: results from Lung Health Study II

OBJECTIVE

To define the relationship between skin bruising (as well as other cutaneous manifestations) and inhaled corticosteroid (ICS) therapy vs placebo in subjects with COPD who were participating in a clinical trial. To explore the relationship between easy skin bruising and other systemic effects of ICS therapy, including adrenal suppression and loss of bone mineral density (BMD).

DESIGN

Double-blind, randomized, placebo-controlled clinical trial of triamcinolone acetonide (1200 microg daily) vs placebo in participants with mild-to-moderate COPD.

SETTING

Lung Health Study II, a clinical trial to assess the effect of ICS compared to placebo in 1,116 participants in 10 centers over > 3.5 to 4.5 years.

PARTICIPANTS

A total of 1,116 smokers or recent ex-smokers with mild-to-moderate COPD (age range, 40 to 69 years; mean age, 56.3 years; 37.2% female).

MEASUREMENTS AND RESULTS

Every 6 months, a structured questionnaire was administered to elicit reports of any bruising and/or skin rashes, slow healing of cuts or sores, or other skin changes. Compliance with inhaler use was assessed by canister weighing. A significantly higher proportion of ICS than placebo participants who complied with using their inhaler reported easy bruising (11.2% vs 3.5%, respectively) and the slow healing of skin cuts or sores (2.4% vs 0.5%, respectively). Older men in the ICS group with good inhaler compliance appeared to be at the greatest risk of bruising. In those participants undergoing serial measurements of adrenal function and BMD, no association was noted between skin bruising and either the suppression of adrenal function or the loss of BMD as systemic complications of ICS use.

CONCLUSION

These findings indicate that moderate-to-high doses of ICSs result in an increased incidence of easy bruising and impairment in skin healing in middle-aged to elderly persons with COPD. No association was noted between skin bruising and other markers of systemic toxicity from the use of ICSs.

Interventions to prevent chronic obstructive pulmonary disease exacerbations

Exacerbations of chronic obstructive pulmonary disease (COPD) have a profound effect on the patient's health status and decline in lung function; they also impose a significant burden on healthcare resource utilization. Prevention and treatment of exacerbations is listed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as among the major objectives of COPD management, and it is therefore an important outcome measure when studying any new agent. This article discusses pharmacologic therapy and other measures for preventing exacerbations and hospitalizations due to exacerbations of COPD.

The pathophysiology of airway dysfunction

Asthma and chronic obstructive pulmonary disease (COPD) are distinct inflammatory disorders with differing pathophysiologic mechanisms, different clinical courses, and, therefore, distinct treatment strategies. Whereas in asthma airflow limitation is typically episodic and reversible, airflow limitation in COPD is progressive and only partially reversible. In contrast to asthma, which is characterized by an elevated number of eosinophils in the blood and the accumulation of elevated numbers of activated eosinophils, mast cells, and CD4+ T(H)2-lymphocytes in the lungs, the primary inflammatory cells present in the lungs of patients with stable COPD are neutrophils, macrophages, and CD8+ lymphocytes. Bronchoconstriction in COPD is largely regulated by cholinergically mediated vagal tone, and the pathologic processes of COPD further reduce airway patency. Bronchodilators, most notably anticholinergics, are recommended as first-line pharmacologic therapy for COPD. Proper use of inhaled anticholinergic medications has been shown to lead to significant reversibility of acetylcholine-mediated bronchoconstriction during both stable disease and exacerbations of COPD. For patients with asthma, current guidelines recommend anti-inflammatory medications, specifically inhaled corticosteroids and leukotriene-modifiers, as first-line therapy, making these agents the mainstay of asthma therapy. In contrast, the current guidelines for COPD management recommend that inhaled anti-inflammatory agents be tried in patients with COPD only as second-line therapy for patients who have severe to very severe airflow obstruction with frequent exacerbations and who remain symptomatic despite maximized bronchodilation with multiple inhaled bronchodilators. Hence, it is extremely important to understand the differences between the underlying pathogenesis and pathophysiology of COPD and those of asthma, as these differences dictate the implementation of distinctly different treatment options for these 2 diseases.

Chronic obstructive pulmonary disease: the clinical management of an acute exacerbation

Exacerbations of chronic obstructive pulmonary disease impose a considerable burden of morbidity, mortality, and health care cost. Management guidelines outlining best practice, based largely on consensus expert opinion, were produced by a number of organisations during the last decade. Current interest in the field is high. This has resulted in the publication of many further studies which have extended our understanding of the pathology involved and provided, for the first time, an evidence base for many of the therapeutic options. In this review we aim to bring the non-specialist reader up to date with current management principles and the evidence underlying such interventions.

Long-term pharmacologic management of patients with chronic obstructive pulmonary disease

Various pharmacologic agents are available for the long-term maintenance management of chronic obstructive pulmonary disease (COPD). The efficacy of these agents is based on their ability to decrease COPD symptoms, improve pulmonary function and quality of life, and reduce the frequency of acute exacerbations. Bronchodilators form the foundation of COPD therapy. Anticholinergic bronchodilators, such as ipratropium bromide and especially tiotropium, are first-line anticholinergic agents that can be used alone or in combination with long-acting or short-acting beta2-agonists to achieve these primary goals of COPD treatment. Methylxanthines are useful primarily for their nonbronchodilatory (ie, positive) effects on pulmonary arterial pressure, pulmonary vascular resistance, renal blood flow, and glomerular filtration rate. Inhaled corticosteroids are reserved only for the few patients with severe disease who experience symptoms and acute exacerbations despite optimized multiple bronchodilator therapy. This article reviews agents that are currently available and those that are in development for the long-term management of COPD, with special emphasis on the anticholinergic bronchodilators.

Mediators of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major and increasing global health problem that is now a leading cause of death. COPD is associated with a chronic inflammatory response, predominantly in small airways and lung parenchyma, which is characterized by increased numbers of macrophages, neutrophils, and T lymphocytes. The inflammatory mediators involved in COPD have not been clearly defined, in contrast to asthma, but it is now apparent that many lipid mediators, inflammatory peptides, reactive oxygen and nitrogen species, chemokines, cytokines, and growth factors are involved in orchestrating the complex inflammatory process that results in small airway fibrosis and alveolar destruction. Many proteases are also involved in the inflammatory process and are responsible for the destruction of elastin fibers in the lung parenchyma, which is the hallmark of emphysema. The identification of inflammatory mediators and understanding their interactions is important for the development of anti-inflammatory treatments for this important disease.

Measuring symptom response to pharmacological interventions in patients with COPD: a review of instruments used in clinical trials

OBJECTIVES

To identify and evaluate the instruments used to measure the effect of pharmacological intervention on symptoms of chronic obstructive pulmonary disease (COPD) in clinical trials.

DESIGN

An extensive literature search was conducted for articles published in English in a peer-reviewed journal from 1995 to March 2002 which described a randomised controlled clinical trial measuring symptoms of COPD in response to pharmacological interventions.

PATIENTS

Patients with any severity of COPD.

INTERVENTIONS

Any pharmacological intervention for treatment of COPD.

MEASUREMENTS AND RESULTS

A total of 43 eligible articles were identified. The individual symptoms most frequently measured were dyspnoea/breathlessness, chest tightness or discomfort and exacerbations. There was considerable variability in the methods, terminology and symptom measurement instruments used. The most widely used instruments for measuring dyspnoea were the Borg scale, the Baseline Dyspnoea Index and the Transitional Dyspnoea Index. None of the instruments used had published evidence of rigorous psychometric testing.

CONCLUSIONS

Numerous methods have been employed to assess the symptoms of COPD in clinical trials, making it difficult to compare the results of different trials. No single measurement instrument predominates, and none of the measures identified in the review have undergone rigorous psychometric testing in this patient population. There is a clear need for a fully developed and validated tool for measuring the effects of therapeutic interventions on symptoms in COPD in clinical trials.

Should general practitioners screen smokers for COPD?

OBJECTIVE

To discuss whether screening for early chronic obstructive lung disease (COPD) is justifiable.

BACKGROUND

The COPD diagnosis can usually be made by means of spirometry before symptoms appear. General practitioners are these days encouraged, from several quarters, to screen their smoking patients for early COPD. Smoking cessation is still the only available treatment that indisputably improves the long-term prognosis of this disease. The argument for screening is that people will be more easily motivated to stop smoking if they know their lung function results. There is, however, no documentation that this is the case.

DATA SOURCES

Pub Med using the search terms "mass screening", "COPD" and "spirometry".

RESULTS

There is no evidence today that spirometry screening aids smoking cessation.

CONCLUSIONS

A large randomized study is needed, in which the independent effect of spirometry as part of a smoking cessation programme is studied. Until such a study has shown convincing results, and has been followed by a cost-benefit analysis in favour of screening, screening for pre-clinical COPD in general practice should not be recommended. However, it is important to diagnose people who may benefit from symptom-relieving treatment, and therefore patients with smoking-related symptoms should be offered spirometry. Finally, the general practitioner should strive to offer smoking cessation counselling to all smokers, regardless of their lung function.

[New therapeutic approaches to COPD]

Classification of severity of the disease is the basis of the therapeutic concept for chronic obstructive lung disease (COPD). Besides pharmacological treatment, preventive measures and rehabilitation with training are the main parts of COPD therapy. Weaning patients of cigarette smoking is of utmost importance in every stage for the course of the disease. Inhalative short acting bronchodilators on demand are the basis of treatment in all stages as well as long acting bronchodilators from stage II on as continuous medication. Theophyllines are of additional importance in higher degrees of the disease. Inhalative steroids are indicated in severe stages III or higher, systemic steroids only during exacerbations as short course therapy. Oxygen long time treatment, intermittent non-invasive ventilation, and operations in some cases are additional therapies.

Pharmacological approaches to stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) causes disabling, slowly progressive breathlessness on exertion, chronic cough and sputum production. Its natural history is punctuated by increasingly frequent exacerbations which in turn accelerate disease progression and reduce a patient's quality of life. COPD has previously been ignored in the mistaken belief that nothing could be done. There are now a number of therapies that can be used to reduce symptoms and prevent exacerbations. In turn this reduces disability, improves the patient's health-related quality of life and has the potential to reduce costs to the health service and to society.

Therapeutic responses in asthma and COPD. Corticosteroids

The effects of inhaled corticosteroids (ICSs) in asthma include reduced severity of symptoms, improved pulmonary function, diminished bronchial hyperresponsiveness (BHR), prevention of exacerbations, and possible prevention of airway wall remodeling. Compared with an inhaled beta(2)-agonist, ICSs improve airway function and BHR, reduce bronchial-epithelium abnormalities, decrease bronchial inflammation, and reduce inflammatory-cell infiltration into the bronchial lamina propria; thus, they may prevent airway remodeling. In children, early use of ICSs may result in improved airway function over time. ICSs reduce use of prednisone, asthma medications, hospitalizations, and urgent-care visits. The primary side effects of ICSs in children are limited to transient reduction in growth. Compared with a leukotriene receptor antagonist (LTRA), ICSs produced a greater change from baseline in FEV(1) and greater reductions in symptoms. A long-acting beta(2)-agonist (LABA) combined with an ICS produced greater improvements than does therapy with ICSs even at higher doses. In COPD, the therapeutic value of ICSs is not as clear. While clinical trials in patients with mild COPD have not shown a reduction in decline in FEV(1) over time, other studies have shown that ICS therapy reduces exacerbations in patients with more severe COPD. Combination therapy with both ICS and LABA has recently been shown to be effective in COPD, where studies have documented additive improvement in FEV(1). Overall, the same therapeutic approaches show clinical effectiveness in both asthma and COPD. This supports the hypothesis that there are some similarities in these obstructive airway diseases. Future approaches should further define phenotypes, perhaps based in part on pharmacogenetic factors that will guide anti-inflammatory therapy in asthma and COPD.

Treatment implications on morbidity and mortality in COPD

Inhaled corticosteroids (ICSs) remain controversial in COPD, although recent clinical trials have consistently found that they reduce chronic respiratory symptoms and, in some population-based studies, improve survival. Their impact on the general COPD population depends on the variability in clinical response among individuals, the magnitude of treatment benefits, and the prevalence of adverse events in the population. The clinical benefits of ICSs in COPD are less obvious than in asthma; however, even patients with COPD without airway hyperresponsiveness experience significant improvement in baseline lung function and other outcomes after treatment with ICS. Population-based surveys suggest that a majority of patients with COPD have asthma or chronic bronchitis features and, therefore, are predisposed to a stronger treatment benefit from ICS. Clinical data support the use of ICS in patients with moderate-to-severe COPD, and suggest that they have impacts on morbidity and mortality that are as great or greater than those seen among commonly accepted treatments for other chronic diseases.

The place of inhaled corticosteroids in chronic obstructive pulmonary disease

The role of systemic corticosteroids in the treatment of exacerbations of chronic obstructive pulmonary disease (COPD) is well established. However, despite being frequently prescribed for the treatment of COPD, the clinical utility of inhaled corticosteroids (ICS) is less clearly defined. This review article seeks to clarify the role of ICS in the clinical management of COPD through a review of key pivotal short-, medium- and long-term studies in this field. Studies for inclusion in this review were identified by means of a computerised search of several databases (including MEDLINE, BIOSIS and EMBASE) from 1980 to 2003. While individual clinical and epidemiological studies have yielded conflicting results, meta-analysis of available data suggests that ICS may reduce the frequency and severity of exacerbations, the number of hospitalisations and the mortality rate, as well as yielding improvements in lung function and health-related quality of life (HRQL) in some subgroups of COPD patients. More recently, clinical trials evaluating the effect of combination therapy with ICS and long-acting beta2-agonists (LABA) have shown significant effects on the prevention of exacerbations and HRQL. Emerging data are expected to clarify the role of ICS in the management of patients with COPD of different severities as well as the place of treatment with ICS/LABA combinations in the management of this chronic and disabling disorder.

Loss of bone density with inhaled triamcinolone in Lung Health Study II

Inhaled glucocorticosteroids (ICS) are commonly prescribed for chronic obstructive pulmonary disease. No adverse effect on bone mineral density (BMD) has been proven. In a randomized double-blind, placebo-controlled trial at seven centers in North America, we recruited 412 current smokers or recent quitters with mild to moderate chronic obstructive pulmonary disease. They used inhaled triamcinolone acetonide, 600 mcg, or placebo, twice daily. We measured femoral neck and lumbar spine BMD at baseline and after 1 and 3 years, and serum osteocalcin at baseline, 3 months, 1 year, and 3 years. After 3 years, BMD at the femoral neck decreased 1.78% more with ICS than with placebo (p < 0.001). More participants in the ICS group experienced 6% or more loss of femoral neck BMD (p = 0.002). Lumbar spine BMD increased in the placebo group by 0.98% but decreased by 0.35% in the ICS group (a difference of 1.33%, p = 0.007). Changes in osteocalcin did not correlate with changes in BMD. Fractures, lost height, or osteoporosis diagnoses were not increased among ICS users compared with placebo users. In summary, the use of inhaled triamcinolone acetonide was associated with loss of BMD at the femoral neck and lumbar spine after 3 years of treatment.

Inhaled corticosteroids in chronic obstructive pulmonary disease: is there a long-term benefit?

PURPOSE OF REVIEW

The use of inhaled corticosteroids is one of the most controversial issues in COPD pharmacotherapy. Experts disagree about the benefits and harms of ICS for patients with COPD, yet a majority of patients with COPD are being treated with inhaled corticosteroids. This is a review of the most recent literature on this subject.

RECENT FINDINGS

Evidence suggests that ICS, with or without a long-acting beta2-agonist, are cost-effective in reducing exacerbation rates and retarding the decline in health status of COPD patients, although they do not significantly modify the rate of decline in FEV1 or change mortality. This discrepancy is likely related to the differences in pathology of COPD when compared with asthma. Evidence also suggests that ICS may be safe regarding the effects on adrenals and bone mineral density. We have yet to identify reliable criteria for predicting a response to ICS in COPD, but it has become clear that in mild disease, no beneficial effect has been demonstrated.

SUMMARY

In contrast to asthma, inhaled corticosteroids should not be used as a first-line medication in patients with COPD. Identification of patients with COPD who might benefit from long-term treatment with ICS remains paramount.

Treatment of stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a readily diagnosable disorder that responds to treatment. Smoking cessation can reduce symptoms and prevent progression of disease. Bronchodilator therapy is key in improvement of lung function. Three classes of bronchodilators-beta agonists, anticholinergics, and theophylline-are available and can be used individually or in combination. Inhaled glucocorticoids can also improve airflow and can be combined with bronchodilators. Inhaled glucocorticoids, in addition, might reduce exacerbation frequency and severity as might some bronchodilators. Effective use of pharmacotherapy in COPD needs integration with a rehabilitation programme and successful treatment of co-morbidities, including depression and anxiety. Treatment for stable COPD can improve the function and quality of life of many patients, could reduce admissions to hospital, and has been suggested to improve survival.

Factors Associated With Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

The purpose of this article is to provide a general review of the current literature on the factors associated with the outcomes of hospitalizations, survival and health-related quality of life in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), highlighting the limitations and the complexities in interpretation of the results of current studies. There is no consensus definition for AECOPD; onsets may be difficult to define and the determination of duration elusive. The prevalence of acute exacerbations of COPD (AECOPD) in the community appears to be underestimated as exacerbations are underreported by patients and their doctors. Hospitalization for COPD is due mainly to severe AECOPDs which drive the cost of care. There are few longitudinal epidemiological studies on factors associated with hospitalizations for AECOPD. The results of current studies do not allow clear differentiation between associations that are predictors of event, the consequences of the event, or indicators of severity. Strategies to reduce severe exacerbations of COPD include pharmacological treatment, vaccinations, pulmonary rehabilitation, and home care programs. The optimal strategy for the reduction of hospitalization in COPD remains unclear. Long-term interventional studies are needed to provide clearer information for the prevention of exacerbations and hospitalizations in COPD.

Inhaled Combination Therapy With Long-Acting β 2 -Agonists and Corticosteroids in Stable COPD

Long-acting beta(2)-agonists (LABAs) have been shown to be effective first-line bronchodilators in the treatment of COPD patients, and inhaled corticosteroids (ICSs) have been shown to reduce the frequency and/or severity of exacerbations in COPD patients. The concomitant use of a LABA and an ICS can influence both airway obstruction (ie, smooth muscle contraction, increased cholinergic tone, and loss of elastic recoil), and airway inflammation (ie, increased numbers of neutrophils, macrophages, and CD8+ lymphocytes, elevated interleukin-8 and tumor necrosis factor-alpha levels, and protease/antiprotease imbalance). They are also able to reduce the total number of bacteria adhering to the respiratory mucosa in a concentration-dependent manner without altering the bacterial tropism for mucosa, and to preserve ciliated cells. Several clinical trials support the concept of inhaled combination therapy with LABAs and corticosteroids in stable COPD patients. This type of therapy not only improves airflow obstruction but also provides clinical benefits, as manifested by sustained reduction in overall symptoms, improvements in health-related quality of life, and reductions in exacerbations. All of these effects are very important because, despite recent advances in our understanding of COPD and its treatment, therapy remains suboptimal for a considerable number of patients.

Efficacy of the novel phosphodiesterase-4 inhibitor BAY 19-8004 on lung function and airway inflammation in asthma and chronic obstructive pulmonary disease (COPD)

Selective inhibitors of phosphodiesterase-4 (PDE4) inhibit the hydrolysis of intracellular cAMP, which may result in bronchodilation and suppression of inflammation. We examined the effect of 1 week treatment with BAY 19-8004 (5 mg once daily), a novel orally administered PDE4 inhibitor, on trough FEV1 and markers of inflammation in induced sputum in patients with asthma or chronic obstructive pulmonary disease (COPD). Seven patients with asthma (mean [SD] FEV1 69.5 [9.3]% predicted; reversibility in FEV1 26.2 [10.1]%; all non-smokers) and 11 patients with COPD (FEV1 58.6 [8.3]% predicted; reversibility in FEV1 6.5 [4.7]%; median [range] 44 [21-90] pack years of smoking) were included in this randomized, double-blind, placebo-controlled trial. FEV1 was measured before and after 1 week of treatment; sputum was induced by 4.5% saline inhalation on the last day of treatment. FEV1 did not improve during either treatment in both patient groups (p>0.2). Sputum cell counts were not different following placebo and BAY 19-8004 treatment in asthma and COPD patients (p>0.2). However, only in patients with COPD, small but significant reductions in sputum levels of albumin and eosinophil cationic protein were observed (p<0.05). In conclusion, 1 week of treatment with the selective PDE4 inhibitor BAY 19-8004 does not affect FEV1 and sputum cell numbers in patients with asthma or COPD. However, such treatment does seem to reduce levels of albumin and eosinophil cationic protein in sputum samples obtained from patients with COPD.

Bronchodilator reversibility in Australian adults with chronic obstructive pulmonary disease

BACKGROUND AND AIMS

Bronchodilator reversibility (BDR) and inhaled corticosteroid (ICS) use were assessed for volunteers who responded to an advertisement requesting current or ex-smokers who were experiencing breathlessness to attend for lung function testing.

METHODS

One hundred and fifty-four volunteers responded. Forced expiratory volume (FEV1) was measured before and after 400 microg of salbutamol. Significant BDR was assessed according to guidelines of: (i) the American Thoracic Society (> or =12% plus 200 mL of baseline FEV1 or forced vital capacity), (ii) the British-Thoracic Society (BTS) (> or =15% plus 200 mL of baseline FEV1), (iii) the European Thoracic Society (> or =10% predicted FEV1), and (iv) the most commonly used criteria in Australia and New Zealand (> or =15% of baseline FEV1).

RESULTS

One hundred and twenty-three subjects (33 female; 40 current smokers; median pack years 48 (range 5-144)) were suitable for analysis (i.e. had no history of asthma, demonstrable airflow limitation and a forced expiratory ratio (FER) of <70%). Twenty (16%) patients had an FEV1 within the normal range but FER of <70%, 24 (20%) patients had mild disease (FEV1 60-80% predicted), 31 (24%) patients had moderate disease (FEV1 40-59% predicted), and 48 (39%) patients had severe disease (FEV1 <40% predicted), according to BTS criteria. Significant BDR was evident in: (i) 58 (47%) subjects by American criteria, (ii) 26 (21%) subjects by British criteria, (iii) 19 (15%) subjects by European criteria and (iv) 36 (29%) subjects by Australasian criteria. ICS use was reported by 71 (58%) subjects overall and was weakly, but significantly, related to poorer FEV1 (r = -0.2; P < 0.01), and greater BDR (r = 0.3; P < 0.005).

CONCLUSION

Chronic obstructive pulmonary disease in Australian volunteers with no history of asthma encompasses many individuals with significant BDR. Interestingly, most volunteers reported ICS use and this was related to poorer spirometry and greater BDR. However, until the underlying immuno-pathology has been determined they cannot be assumed to have "asthma" or even an "asthmatic element".

Comparison of Oral and Depot Intra‐muscular Steroids in Assessing Steroid‐Responsiveness in COPD

Non-compliance or euphoria may limit the usefulness of prednisolone tablets in assessing steroid-responsiveness in chronic obstructive pulmonary disease (COPD). Depot intra-muscular methyl-prednisolone (imMP), producing a plateau steroid effect over two weeks, may be more reliable. Following two weeks of placebo, twenty-seven COPD patients (mean FEV 1 43% predicted) participated in a two-week randomised, double-blind, placebo-controlled, parallel-design trial taking either 120 mg imMP with placebo tablets or placebo injection with prednisolone 30 mg daily. After each period, post-bronchodilator FEV 1, forced vital capacity (FVC), inspiratory capacity (IC) and six-minute walking distance (6MWD) were assessed and patients completed both quality-of-life scores (St. George's 30 and Short Form 36) and mood scores (Hospital Anxiety and Depression scores and Altman's Self-rating Mania Scale). There were no significant changes in 6MWD, quality of life or mood scores after either type of steroids and no change in lung function after imMP. By contrast, there were small mean improvements in lung function on oral prednisolone (mean FEV 1, FVC and IC increased by 100, 320 and 150 ml, respectively). Only the improvement in FVC was significantly greater after prednisolone compared with imMP. Single depot intra-muscular injections of steroids have no advantage over oral daily prednisolone in testing steroid-responsiveness in COPD patients.

New therapies for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the most common lung disease, carrying a significant mortality and morbidity. None of the therapeutic interventions currently available alter the progression of the disease. As our understanding of the basic mechanisms of alveolar destruction and airflow limitation improves, new targets are identified that may eventually result in treatment options which will affect the progression of this disease. In this review, we discuss some of the novel therapeutic options recently developed that may have an impact on the management of COPD. Future directions in research and development of pharmacological agents based on improved understanding of COPD are also discussed.

Effect of inhaled fluticasone propionate on BAL TGF-β1 and bFGF concentrations in clinically stable lung transplant recipients

BACKGROUND

Inhaled fluticasone propionate (FP) therapy decreases inflammation and sub-basement membrane thickness in asthmatic airways. Bronchiolitis obliterans syndrome (BOS) in lung transplant recipients (LTRs) involves progressive airway fibrosis and obliteration. Therefore, augmented immunosuppression may be of some benefit in treating BOS. In this study, we examined the effect of 3 months of treatment with high-dose inhaled FP on the concentrations of 2 fibrogenic factors, transforming growth factor (TGF)-beta(1) and beta fibrogenic growth factor (bFGF) in bronchoalveolar lavage (BAL) fluid from clinically stable LTRs.

METHODS

We conducted a randomized, double-blind, placebo-controlled, parallel group study with inhaled FP (750 microg, twice/day for 3 months) in 28 LTRs (15 FP and 13 placebo). We recruited 23 healthy controls. We performed spirometry, bronchoscopy, and bronchoalveolar lavage procedures before treatment and after 3 months of treatment. We used commercially available enzyme-linked immunosorbent assay kits to measure BAL fluid TGF-beta(1) and bFGF concentrations.

RESULTS

In LTRs before treatment, BAL TGF-beta(1) concentrations (but not bFGF concentrations), total cell counts, and neutrophil percentage increased compared with controls (p < 0.05). We found no significant differences between FP and placebo groups at baseline measurements. After treatment, BAL TGF-beta(1) concentrations significantly increased in the FP group (p = 0.03), but we found no difference between FP and placebo groups; BAL bFGF concentrations increased during treatment in both groups compared with controls (p < 0.05), but not significantly within either patient group (p > 0.05). We found a reverse correlation between forced expiratory volume in 1 second (FEV(1)) and BAL TGF-beta(1) concentration in the FP group (r = -0.53, p = 0.04), and between FEV(1) and BAL TGF-beta(1) concentration in the placebo group (r = -0.74, p = 0.004). Multivariable analysis indicated no significant independent effects of inhaled FP in either BAL TGF-beta(1) or bFGF concentrations.

CONCLUSIONS

Bronchoalveolar fluid TGF-beta(1) concentrations increased in LTRs after transplantation and may correlate with the decrease in lung function. Inhaled FP added to conventional immunosuppression had no effect on TGF-beta(1) or bFGF production in BAL fluid.

Severe chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) exacts a heavy toll on society, yet its prevention, diagnosis and treatment receives inadequate attention from both the medical community and from society at large. Guidelines released in 2001 from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) are aimed at redressing this inequity. In this review, we integrate information from the GOLD guidelines with recent updates on the prevention, treatment and management as related specifically to the most severe form of this disease. In order to help distinguish COPD from other disorders that may mimic or confound its treatment, we place particular emphasis on the definition, underlying pathophysiology and diagnosis of COPD. In addition, we discuss future directions in pharmacotherapy.

[Pulmonary diseases in the elderly. Problems of pharmacotherapy]

In asthma, inhaled corticosteroids (ICS) can be regarded as disease-modifying drugs. They represent the mainstay of pharmacotherapy of asthma. In elderly, ICS are currently underused. In chronic obstructive pulmonary disease (COPD), there is recent evidence to suggest that ICS may reduce the rate and severity of COPD exacerbations and may improve health-related quality of life. Particularly patients with moderate-to-severe COPD appear to benefit from ICS therapy. In both asthma and COPD, fixed combinations of ICS and long-acting beta 2-agonists may provide clinically meaningful benefits to patients and may represent a further therapeutic advantage.

Pharmacologic treatment of chronic obstructive pulmonary disease: past, present, and future

Pharmacologic treatment of chronic obstructive pulmonary disease (COPD) has evolved considerably during the past several decades. Initial treatment of the disease was accomplished primarily through antibiotics, mucolytic agents, and nonselective sympathomimetic agents. Up-to-date treatment guidelines stratified according to strength of evidence are published in the National Heart, Lung, and Blood Institute-World Health Organization workshop report on the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Current drug therapy for stable COPD focuses primarily on bronchodilation through inhaled beta2-agonists and anticholinergic agents, immunization, and elimination of smoking as a risk factor. Although many pharmacologic agents are available to treat COPD, no drug has demonstrated effectiveness in halting progression of the disease. Rather, the goal of drug therapy at this time is to maintain control of symptoms and prevent COPD exacerbations. Compared with asthma, research into treatment for COPD has been minimal. However, a long-acting anticholinergic agent, tiotropium, has received approval status by the United States Food and Drug Administration. The drug has been shown to improve spirometric parameters, quality of life, and utilization of health care resources. In addition, several new targets for the treatment of COPD are being studied, and a few agents, including some that theoretically may slow functional decline in patients with COPD, are in development.

Cost-effectiveness of inhaled corticosteroids for chronic obstructive pulmonary disease according to disease severity

PURPOSE

Inhaled corticosteroids reduce exacerbations in patients with chronic obstructive pulmonary disease (COPD), but their cost-effectiveness is not known.

METHODS

We used a Markov model to determine, from a societal perspective, the cost-effectiveness of four treatment strategies involving inhaled corticosteroids: no use regardless of COPD severity; use in all disease stages; use in patients with stage 2 or 3 disease (forced expiratory volume in 1 second [FEV(1)] <50% of predicted); and use in patients with stage 3 disease (FEV(1) <35% of predicted). Data from the literature were used to estimate mortality, exacerbation, and disease progression rates, as well as the costs associated with care and quality-adjusted life-years (QALYs), according to disease stage and use or nonuse of inhaled corticosteroids. A time horizon of 3 years was used.

RESULTS

Use of inhaled corticosteroids in patients with stage 2 or 3 disease was associated with a cost of 17,000 dollars per QALY gained. In stage 3 patients, use resulted in a cost of 11,100 dollars per QALY gained. Providing inhaled corticosteroids to all COPD patients was associated with a less favorable cost-effectiveness ratio. Results were robust to various assumptions in a Monte Carlo simulation.

CONCLUSION

In patients with COPD, use of inhaled corticosteroids in those with stage 2 or 3 disease for 3 years results in improved quality-adjusted life expectancy at a cost that is similar to that of other therapies commonly used in clinical practice.

Managing COPD: no more nihilism!

This special issue of Patient Education and Counseling is long overdue. During most of the last two decades asthma, and notably asthma self-management has been in the spotlight, while COPD has had to endure a nihilistic approach. The first sign that interest was shifting to the treatment of COPD came from a few large randomized trials on the use of inhaled corticosteroids (ICS) in COPD. Although these studies demonstrated a moderate effect of ICS in COPD, it has become clear that true improvements in the management of this chronic disease will have to come from behavioral interventions. This special issue of Patient Education and Counseling is dedicated solely to the non-pharmaceutical management of COPD. It addresses many issues related to behavioral therapy, such as smoking cessation, exercise training, nutritional aspects, and self-management programs, including action plans to self-treat exacerbations. With the availability of all the treatment and management options, described in this special issue, a nihilistic attitude toward the patient with COPD is no longer justified.

COPD exacerbations: the importance of a standard definition

Efforts to assess the efficacy of new therapies in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD) have been hampered by the lack of a widely agreed and consistently used definition. A variety of definitions have been used in clinical studies, based on changes in patient symptoms or the requirement for antibiotic therapy, oral steroids or hospitalisation. To date, none of these definitions have been assessed in detail for their reliability, responsiveness and validity determined. Considerable heterogeneity in the aetiology and manifestation of COPD exacerbations makes identification and quantification of defining symptoms extremely difficult. New approaches are therefore being sought with a view to identifying a serum or tissue marker that can be used as a valuable diagnostic tool. Improvements in data recording will also contribute to the accuracy of data retrieval and assessment. If we are to progress to a level of sophistication seen in the diagnosis and management of other diseases, it is evident that considerable research efforts will be required to improve our understanding of COPD exacerbations and develop a standard definition for these events, thereby facilitating the assessment of therapeutic approaches.

Combined corticosteroid and long acting beta-agonist in one inhaler for chronic obstructive pulmonary disease

BACKGROUND

Long-acting beta-agonists and inhaled corticosteroids have both been recommended in guidelines for the treatment of chronic obstructive pulmonary disease. Their co-administration in a combined inhaler is intended to facilitate adherence to medication regimens, and to improve efficacy.

OBJECTIVES

To assess the efficacy of combined inhaled corticosteroid and long-acting beta-agonist preparations, compared to placebo or the individual components, in the treatment of adults with chronic obstructive pulmonary disease.

SEARCH STRATEGY

We searched the Cochrane Airways Group chronic obstructive pulmonary disease (COPD) trials register. Date of last search April 2004.

SELECTION CRITERIA

Studies were included if they were randomised and double-blind. Studies could compare a combined inhaled corticosteroids and long-acting beta-agonist preparation with either component preparation or placebo.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. The primary outcome was exacerbations.

MAIN RESULTS

Six randomised trials with 4118 participants were included. Two different combination preparations (fluticasone/salmeterol and budesonide/formoterol) were used. Combination treatment was more effective than placebo for mean exacerbation rates, quality of life and lung function. No trials were found comparing the combination of drugs in a single inhaler with the same drugs both given in separate inhalers. Exacerbations: Fluticasone/salmeterol did not significantly reduce exacerbations compared with either of its component treatments in one large study. There was no significant difference when budesonide/formoterol was compared with budesonide. Budesonide/formoterol was more effective than formoterol in reducing exacerbations (Rate ratio: 0.78 [0.68 to 0.90], two studies). A pooled analysis of both combination therapies indicated that exacerbations were less frequent when compared with either placebo or long-acting beta-agonist (versus placebo Rate ratio: 0.76 [0.68, 0.84], three studies, versus beta-agonist, Rate ratio: 0.85 [0.77, 0.95], three studies), but not when compared with steroid. The clinical impact of this effect depends on the frequency of exacerbations experienced by patients. One full exacerbation was prevented for every two to four years of treatment in the type of patients included in the trials. Quality of Life: There were conflicting findings in quality of life and symptoms when fluticasone/salmeterol was compared with inhaled steroids alone (three studies). There was no significant difference between fluticasone/salmeterol and long-acting beta-agonist in quality of life scores (three studies). Budesonide/formoterol improved symptoms when compared with budesonide but not with formoterol. There were conflicting findings in quality of life scores when budesonide/formoterol was compared with component inhaled corticosteroid or beta-agonist. These may be accounted for by different study design. Lung Function: Treatment with either combination led to small, significant differences in lung function compared with component steroid medication. Fluticasone/salmeterol led to small improvements in FEV1 compared with salmeterol, but budesonide/formoterol treatment did not increase FEV1 significantly when compared with formoterol.

REVIEWERS' CONCLUSIONS

Compared with placebo, combination therapy led to clinically meaningful differences in quality of life, symptoms and exacerbations. However, there were conflicting results when the different combination therapies were compared with the mono-components alone. In order to draw firmer conclusions about the effects of combination therapy in a single inhaler more data are necessary, including the assessment of the comparative effects with separate administration of the two drugs in double-dummy trials.

Medical management of chronic obstructive pulmonary disease

Recent advances in the treatment of patients who have COPD include the development of long-acting bronchodilators, recognition of the benefits of ICS, and development of effective initiation and maintenance pulmonary rehabilitation programs. The focus on outcome parameters other than expiratory flow rates, such as symptoms, quality of life, exercise tolerance, and exacerbation frequency, might also allow effective development of novel disease-modifying agents.

Withdrawal from treatment as an outcome in the ISOLDE study of COPD

OBJECTIVES

To investigate the determinants of patient withdrawal from our study, and the effect of these withdrawals on the outcome of treatment with inhaled corticosteroids in patients with COPD.

DESIGN

A double-blind, placebo-controlled, randomized trial.

SETTING

Eighteen outpatient centers in the United Kingdom.

PARTICIPANTS

Seven hundred fifty-one patients with stable COPD defined clinically and as baseline postbronchodilator FEV(1) > or = 0.8 L and < 85% predicted, FEV(1)/FVC ratio < 70%, and FEV(1) change after albuterol < 10% of predicted.

INTERVENTION

Random assignment of either 500 microg bid of inhaled fluticasone propionate (FP) using a spacer device or an identical placebo inhaler. Treatment was continued for 3 years or until patients withdrew from follow-up.

MEASUREMENTS AND RESULTS

Postbronchodilator FEV(1) was measured on three occasions before randomization and every 3 months thereafter. Health status was assessed by the disease-specific St. George Respiratory Questionnaire (SGRQ) and the modified short-form 36 questionnaire (SF-36) at baseline and every 6 months. Three hundred thirty-nine patients withdrew, of whom 156 patients received FP. Prescription of frequent courses of oral prednisolone was the most common reason for withdrawing as specified in the protocol (69 patients in the FP group withdrew due to respiratory symptoms, compared with 93 patients in the placebo group). This explained the significantly greater dropout of placebo-treated patients that was most evident when FEV(1) was < 50% predicted. Patients withdrawing had a significantly more rapid decline in health status, measured by both the SGRQ and the SF-36 (p < 0.001). Those withdrawing from the placebo group had a more rapid decline in FEV(1) and more exacerbations than the FP-treated groups. Baseline FEV(1) was lower in dropouts than in patients completing the study receiving placebo, but there was no difference between the respective groups receiving FP.

CONCLUSIONS

Patients who withdrew from follow-up were those with the most rapidly deteriorating health status and lung function. Losing these patients from the final analysis can reduce the power of a study to achieve its primary end point.

Short- and long-term efficacy of fluticasone propionate in subjects with early signs and symptoms of chronic obstructive pulmonary disease. Results of the DIMCA study

BACKGROUND

Early treatment with inhaled corticosteroids may prevent progression of irreversible obstruction in COPD, especially in patients with bronchial hyperresponsiveness. We investigated the clinical effects of early introduction of inhaled steroids in subjects showing early signs and symptoms of COPD without a prior clinical diagnosis.

METHODS

Study subjects were detected in a general population screening and monitoring program. Those with a moderately accelerated annual FEV1 decline and persistent respiratory symptoms were invited to participate in a 2-year randomized controlled trial comparing fluticasone propionate DPI 250 microg b.i.d. with placebo. Pre- and post-bronchodilator (BD) FEV1, PC20 histamine, functional status (COOP/WONCA charts) and occurrence of exacerbations were periodically assessed. Subjects recorded respiratory symptoms. Post-BD FEV1 decline served as the main outcome. Multivariable repeated measurements analysis techniques were applied.

RESULTS

48 subjects were randomized (24 fluticasone, 24 placebo). After 3 months, the post-BD FEV1 had increased with 125 ml (SE = 68, P = 0.075) and the pre-BD FEV1 with 174 ml (SE 90, P = 0.059) in the fluticasone relative to the placebo group. The subsequent post-BD and pre-BD FEV1 decline were not beneficially modified by fluticasone treatment. There were no statistically significant differences in respiratory symptoms, functional status, or exacerbations favoring fluticasone. Subgroup analysis indicated that the presence of bronchial hyperresponsiveness modified the initial FEV1 response on fluticasone, but not the subsequent annual FEV1 decline.

CONCLUSION

Early initiation of inhaled steroid treatment does not seem to affect the progressive deterioration of lung function or other respiratory health outcomes in subjects with early signs and symptoms of COPD. In subjects at risk for, or in an early stage of COPD, long-term inhaled steroid treatment should not be based on a single spirometric evaluation after 3 months.

Inhaled corticosteroids reduce the progression of airflow limitation in chronic obstructive pulmonary disease: a meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a syndrome of chronic progressive airflow limitation which occurs as a result of chronic inflammation of the airways and lung parenchyma. However, the role of inhaled corticosteroids in the treatment of COPD is controversial. We hypothesised that inhaled corticosteroids reduce the progression of airflow limitation in COPD.

METHODS

A comprehensive literature search was conducted and data were analysed using random effects methodology. The effect of inhaled steroids on annual change in forced expiratory volume in 1 second (FEV1) was determined for all trials, for trials with high dose treatment regimens, and for trials in subjects with moderate to severe airflow limitation.

RESULTS

Data from eight controlled clinical trials of > or =2 years were included (n=3715 subjects). Meta-analysis of all study data revealed that inhaled corticosteroids reduce the rate of FEV1 decline by 7.7 ml/year (95% confidence interval (CI) 1.3 to 14.2, p=0.02). Meta-analysis of studies with high dose regimens revealed a greater effect of 9.9 ml/year (95% CI 2.3 to 17.5, p=0.01) compared with the meta-analysis of all studies.

CONCLUSIONS

Inhaled corticosteroid treatment for > or =2 years slows the rate of lung function decline in COPD. The effect observed with high dose regimens is greater than that with all regimens combined. These data suggest a potential role for inhaled corticosteroids in modifying the long term natural history of COPD.

Contemporary management of chronic obstructive pulmonary disease: scientific review

CONTEXT

The care of patients with chronic obstructive pulmonary disease (COPD) has changed radically over the past 2 decades, and novel therapies can not only improve the health status of patients with COPD but also modify its natural course.

OBJECTIVE

To systematically review the impact of long-acting bronchodilators, inhaled corticosteroids, nocturnal noninvasive mechanical ventilation, pulmonary rehabilitation, domiciliary oxygen therapy, and disease management programs on clinical outcomes in patients with COPD.

DATA SOURCES

MEDLINE and Cochrane databases were searched to identify all randomized controlled trials and systematic reviews from 1980 to May 2002 evaluating interventions in patients with COPD. We also hand searched bibliographies of relevant articles and contacted experts in the field.

STUDY SELECTION AND DATA EXTRACTION

We included randomized controlled trials that had follow-up of at least 3 months and contained data on at least 1 of these clinical outcomes: health-related quality of life, exacerbations associated with COPD, or death. For pulmonary rehabilitation, we included studies that had a follow-up of at least 6 weeks. Using standard meta-analytic techniques, the effects of interventions were compared with placebo or with usual care. In secondary analyses, the effects of interventions were compared against each other, where possible.

DATA SYNTHESIS

Long-acting beta2-agonists and anticholinergics (tiotropium) reduced exacerbation rates by approximately 20% to 25% (relative risk [RR] for long-acting beta2-agonists, 0.79; 95% CI, 0.69-0.90; RR for tiotropium, 0.74; 95% CI, 0.62-0.89) in patients with moderate to severe COPD. Inhaled corticosteroids also reduced exacerbation rates by a similar amount (RR, 0.76; 95% CI, 0.72-0.80). The beneficial effects were most pronounced in trials enrolling patients with FEV1 between 1 L and 2 L. Combining a long-acting beta2-agonist with an inhaled corticosteroid resulted in an approximate 30% (RR, 0.70; 95% CI, 0.62-0.78) reduction in exacerbations. Pulmonary rehabilitation improved the health status of patients with moderate to severe disease, but no material effect was observed on long-term survival or hospitalization rates. Domiciliary oxygen therapy improved survival by approximately 40% in patients with PaO2 lower than 60 mm Hg, but not in those without hypoxia at rest. The data on disease management programs were heterogeneous, but overall no effect was observed on survival or risk of hospitalization. Noninvasive mechanical ventilation was not associated with improved outcomes.

CONCLUSIONS

A significant body of evidence supports the use of long-acting bronchodilators and inhaled corticosteroids in reducing exacerbations in patients with moderate to severe COPD. Domiciliary oxygen therapy is the only intervention that has been demonstrated to prolong survival, but only in patients with resting hypoxia.

[Chronic obstructive lung disease]

The chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. Recently, international guidelines for diagnosis, prevention and therapy have been published. Now also a modified German version of these guidelines is available. The diagnosis and the severity of the disease is established on the basis of spirometric findings. All stages of COPD are treated with bronchodilators (beta 2-sympathomimetics and anticholinergics). In addition, in stage II and III theophylline and inhaled corticosteroids may be used. Systemic steroids should be restricted to acute exacerbations. For patients with advanced COPD long-term oxygen therapy and in selected cases surgical procedures may be indicated. Rehabilitation measures are of high value. Strategies for primary prevention and smoking cessation programs are extremely important. To get to the diagnosis of COPD as early as possible, all smokers with cough and phlegm should undergo spirometry.

Inhaled corticosteroids: past lessons and future issues

Inhaled corticosteroids play a pivotal role in the treatment of asthma. Inhalation permits effective delivery of the corticosteroid in high concentration to target sites within the lung while minimizing systemic exposure. Consequently, the safety profile of inhaled corticosteroids is markedly better than that of oral corticosteroid therapy. However, although it was first thought that direct delivery might eliminate systemic adverse effects, this has not been confirmed by clinical trials and experience. Inhaled corticosteroids are absorbed from the lungs into the systemic circulation, in which they can acutely decrease growth velocity in children, an effect that fortunately appears to be temporary and might have no effect on final adult height. In sufficient dosages, they also produce bone mineral loss leading to osteoporosis and might increase the risk of cataracts, glaucoma, skin atrophy, and vascular changes that increase the risk of ecchymoses. Effective evaluation of the severity and significance of these complications is challenging because highly sensitive tests do not reliably predict clinically significant events, and short-term observations do not predict long-term consequences. Also, compliance wanes with long-term treatment, and susceptibility to a particular adverse event can vary over time, even in the same individual, because of developmental or hormonal changes. This journal supplement will review what has been learned about the safety of inhaled cortico-steroids during the past decade, discussing some of the questions that remain and considering the characteristics of an "ideal" inhaled corticosteroid: one with high local activity in the lung and minimal or no adverse systemic effects.

Inhaled corticosteroids in chronic obstructive pulmonary disease and risk of death and hospitalization: time-dependent analysis

Observational studies of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD) have shown improved survival whereas randomized trials have not. It has been suggested that this difference may be due to immortal time bias. To investigate this further, we performed a prospective cohort study of patients with COPD, using time-dependent methods to determine whether use of inhaled corticosteroids more than 80% of the time reduced the risk of all-cause mortality and COPD exacerbations. Of 8,033 patients, 2,686 (33%) received inhaled corticosteroids. We did not find a significant reduction in mortality for average inhaled steroid use at either low (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.69-1.33) or medium/high dose (HR, 0.86; 95% CI, 0.67-1.10). Similarly, recent inhaled corticosteroid use was not associated with a reduction in mortality at low (HR, 0.80; 95% CI, 0.60-1.07) or medium/high doses (HR, 0.88; 95% CI, 0.71-1.09). There was no association between inhaled corticosteroid use and hospitalizations or exacerbations due to COPD. Patients using medium/high-dose inhaled corticosteroids did not have a significantly lower risk of COPD hospitalizations (HR, 0.85; 95% CI, 0.64-1.13) or COPD exacerbations (HR, 1.13; 95% CI, 0.94-1.36). In a time-dependent study of outpatients with COPD, adherence to inhaled corticosteroid use was not associated with a decreased risk of mortality or exacerbations.

Prevalence of esophageal candidiasis among patients treated with inhaled fluticasone propionate

OBJECTIVES

Development of oropharyngeal candidiasis is a frequently reported adverse effect of inhaled corticosteroid use, but the prevalence of esophageal candidiasis is unknown. The aim of this study was to estimate the prevalence of esophageal candidiasis among patients treated with an inhaled corticosteroid, fluticasone propionate.

METHODS

Upper GI endoscopy was performed on 49 patients treated with inhaled fluticasone propionate to examine the prevalence of esophageal candidiasis. Of the patients, 36 had bronchial asthma and 13 had chronic obstructive pulmonary disease. To compare the prevalence with control patients, upper GI endoscopy was performed on 700 consecutive patients without malignancy or immunosuppression.

RESULTS

The prevalence of esophageal candidiasis was 37% among patients treated with inhaled fluticasone propionate, whereas only 0.3% of the control patients had the infection. The prevalence was especially high among patients with diabetes mellitus or those who were treated with a high dose of inhaled fluticasone propionate. Moreover, a reduction in the daily dose of inhaled fluticasone propionate eliminated the infection in four of five patients.

CONCLUSIONS

Esophageal candidiasis is a common complication of inhaled corticosteroid use.

Inhaled corticosteroids in chronic obstructive pulmonary disease and disseminated aspergillosis

Inhaled corticosteroids are widely used in patients with chronic obstructive pulmonary disease (COPD), although their efficacy is still being debated. Due to local and systemic effects, such therapy can have an immunosuppressive action and opportunistic infections can occur. In the present case, a 74-year-old man treated with inhaled corticosteroids for 5 years developed disseminated aspergillosis. No other immunosuppressive factor was found. To our knowledge, only a few cases of lung aspergillosis in such patients have been described in the literature. However, the risk-to-benefit ratio of this treatment must be reassessed.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of death and disability worldwide. Recognition that the burden of this disorder will continue to increase over the next 20 years despite medical intervention has stimulated new research into the underlying mechanisms, leading to a rational basis for evaluation of existing therapies, and has suggested novel treatment approaches. Tobacco exposure remains the main but not exclusive cause of COPD. Whether the lung is injured by changes in the balance of proteases and antiproteases, tissue damage by oxidative stress, or a combination of the two is still not known. The genetic basis of susceptibility to COPD is now being studied as is the role of computed tomography in the identification of structural damage in individuals with less symptomatic disease. Clinical diagnosis still relies heavily on an appropriate history confirmed by abnormal spirometry. Smoking cessation is possible in a substantial proportion of individuals with symptoms but is most effective if withdrawal is supported by pharmacological treatment. Treatment with long-acting inhaled bronchodilators and, in more severe disease, inhaled corticosteroids reduces symptoms and exacerbation frequency and improves health status. Rehabilitation can be even more effective, at least for a year after the treatment. Recent guidelines have made practical suggestions about how to optimise these treatments and when to consider addition of oxygen, surgery, and non-invasive ventilation. Regular review of this guidance is important if future management advances are to be implemented effectively.

Does a single dose of the phosphodiesterase 4 inhibitor, cilomilast (15 mg), induce bronchodilation in patients with chronic obstructive pulmonary disease?

Maintenance treatment with PDE(4) inhibitor cilomilast improves FEV(1) in chronic obstructive pulmonary disease (COPD) patients. We investigated the acute bronchodilating effects of a single dose of cilomilast with or without concomitant administration of inhaled salbutamol and/or ipratropium bromide in 21 patients with COPD (mean (SD) age 64 (8.1) y, post-salbutamol FEV(1) 47.7 (13.2) %predicted). FEV(1) was measured before and up to 8 hourly intervals after intake of placebo, cilomilast, or cilomilast in combination with inhaled salbutamol 400 microg and/or ipratropium bromide 80 microg. Maximum increase in FEV(1) from pre-dose baseline was calculated after each treatment and differences between treatment arms were analyzed by ANOVA. The mean (SEM) maximum increase in FEV(1) was 139.6 (18.5) ml following cilomilast and 151.5 (18.5) ml following placebo (95% C.I. for mean difference between cilomilast and placebo: -67.3, 43.6 ml). Furthermore, combined treatment of cilomilast with salbutamol or ipratropium resulted in a maximum increase in FEV(1) of 280.7 (25.6) and 297.0 (25.9) ml, respectively, while this was 379.0 (24.6) ml following cilomilast with both salbutamol and ipratropium (p < 0.01). We conclude that a single dose of cilomilast does not produce acute bronchodilation in patients with COPD who otherwise respond to inhaled bronchodilators. Our results implicate that the change in lung function seen after long-term treatment with cilomilast is not the result of acute bronchodilation in patients with COPD.