Efficacy of inhaled steroids in undiagnosed subjects at high risk for COPD: results of the detection, intervention, and monitoring of COPD and asthma program

Inhaled corticosteroids versus placebo for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much uncertainty. COPD clinical guidelines currently recommend selective use of ICS. ICS are not recommended as monotherapy for people with COPD, and are only given in combination with long-acting bronchodilators due to greater efficacy of combination therapy. Incorporating and critiquing newly published placebo-controlled trials into the monotherapy evidence base may help to resolve ongoing uncertainties and conflicting findings about their role in this population.

OBJECTIVES

To evaluate the benefits and harms of inhaled corticosteroids, used as monotherapy versus placebo, in people with stable COPD, in terms of objective and subjective outcomes.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was October 2022.

SELECTION CRITERIA

We included randomised trials comparing any dose of any type of ICS, given as monotherapy, with a placebo control in people with stable COPD. We excluded studies of less than 12 weeks' duration and studies of populations with known bronchial hyper-responsiveness (BHR) or bronchodilator reversibility.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our a priori primary outcomes were 1. exacerbations of COPD and 2. quality of life. Our secondary outcomes were 3. all-cause mortality, 4. lung function (rate of decline of forced expiratory volume in one second (FEV1)), 5. rescue bronchodilator use, 6. exercise capacity, 7. pneumonia and 8. adverse events including pneumonia. ]. We used GRADE to assess certainty of evidence.

MAIN RESULTS

Thirty-six primary studies with 23,139 participants met the inclusion criteria. Mean age ranged from 52 to 67 years, and females were 0% to 46% of participants. Studies recruited across the severities of COPD. Seventeen studies were of duration longer than three months and up to six months and 19 studies were of duration longer than six months. We judged the overall risk of bias as low.  Long-term (more than six months) use of ICS as monotherapy reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: rate ratio 0.88 exacerbations per participant per year, 95% confidence interval (CI) 0.82 to 0.94; I2 = 48%, 5 studies, 10,097 participants; moderate-certainty evidence; pooled means analysis: mean difference (MD) -0.05 exacerbations per participant per year, 95% CI -0.07 to -0.02; I2 = 78%, 5 studies, 10,316 participants; moderate-certainty evidence). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60; I2 = 0%; 5 studies, 2507 participants; moderate-certainty evidence; minimal clinically importance difference 4 points). There was no evidence of a difference in all-cause mortality in people with COPD (odds ratio (OR) 0.94, 95% CI 0.84 to 1.07; I2 = 0%; 10 studies, 16,636 participants; moderate-certainty evidence). Long-term use of ICS  reduced the rate of decline in FEV1 in people with COPD (generic inverse variance analysis: MD 6.31 mL/year benefit, 95% CI 1.76 to 10.85; I2 = 0%; 6 studies, 9829 participants; moderate-certainty evidence; pooled means analysis: 7.28 mL/year, 95% CI 3.21 to 11.35; I2 = 0%; 6 studies, 12,502 participants; moderate-certainty evidence).

ADVERSE EVENTS

in the long-term studies, the rate of pneumonia was increased in the ICS group, compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.38, 95% CI 1.02 to 1.88; I2 = 55%; 9 studies, 14,831 participants; low-certainty evidence). There was an increased risk of oropharyngeal candidiasis (OR 2.66, 95% CI 1.91 to 3.68; 5547 participants) and hoarseness (OR 1.98, 95% CI 1.44 to 2.74; 3523 participants). The long-term studies that measured bone effects generally showed no major effect on fractures or bone mineral density over three years. We downgraded the certainty of evidence to moderate for imprecision and low for imprecision and inconsistency.

AUTHORS' CONCLUSIONS

This systematic review updates the evidence base for ICS monotherapy with newly published trials to aid the ongoing assessment of their role for people with COPD. Use of ICS alone for COPD likely results in a reduction of exacerbation rates of clinical relevance, probably results in a reduction in the rate of decline of FEV1 of uncertain clinical relevance and likely results in a small improvement in health-related quality of life not meeting the threshold for a minimally clinically important difference. These potential benefits should be weighed up against adverse events (likely to increase local oropharyngeal adverse effects and may increase the risk of pneumonia) and probably no reduction in mortality. Though not recommended as monotherapy, the probable benefits of ICS highlighted in this review support their continued consideration in combination with long-acting bronchodilators. Future research and evidence syntheses should be focused in that area.

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

OBJECTIVES

To determine the efficacy and safety of inhaled corticosteroids in stable patients with COPD, in terms of objective and subjective outcomes.

SEARCH METHODS

A pre-defined search strategy was used to search the Cochrane Airways Group Specialised Register for relevant literature. Searches are current as of July 2011.

SELECTION CRITERIA

We included randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta(2)-agonists and bronchial hyper-responsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. We also analysed data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Fifty-five primary studies with 16,154 participants met the inclusion criteria. Long-term use of ICS (more than six months) did not consistently reduce the rate of decline in forced expiratory volume in one second (FEV(1)) in COPD patients (generic inverse variance analysis: mean difference (MD) 5.80 mL/year with ICS over placebo, 95% confidence interval (CI) -0.28 to 11.88, 2333 participants; pooled means analysis: 6.88 mL/year, 95% CI 1.80 to 11.96, 4823 participants), although one major trial demonstrated a statistically significant difference. There was no statistically significant effect on mortality in COPD patients (odds ratio (OR) 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long-term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: MD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants; pooled means analysis: MD -0.19 exacerbations per patient per year, 95% CI -0.30 to -0.08, 2253 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.65, 95% CI 2.03 to 3.46, 5586 participants) and hoarseness. In the long-term studies, the rate of pneumonia was increased in the ICS group compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.56, 95% CI 1.30 to 1.86, 6235 participants). The long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years.

AUTHORS' CONCLUSIONS

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life and possibly reduced rate of decline in FEV(1)) against the potential side effects (oropharyngeal candidiasis and hoarseness, and risk of pneumonia).

Do family physicians' records fit guideline diagnosed COPD?

BACKGROUND

In family practice, chronic obstructive pulmonary disease (COPD) is usually not diagnosed until clinically apparent and of moderately advanced severity.

OBJECTIVE

To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands.

METHODS

The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians' (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs' diagnosis of COPD.

RESULTS

After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1-4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3-83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice.

CONCLUSIONS

There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.

Role of early detection and pharmacotherapy in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is defined as airflow limitation that is not fully reversible, usually progressive and associated with an abnormal inflammatory response to noxious particles or gases. By the time COPD has progressed to the point of clinical symptoms, over half of lung function may have been lost. This review will first describe studies that have examined the feasibility and yield of early detection of COPD using spirometry as a gold standard. Next, we will review existing studies that have examined the effects of pharmacotherapy on early (mild-to-moderate) COPD, specifically focusing on studies that have attempted to alter the natural history of disease. Finally, we will briefly discuss studies that have tested the effects of various pharmacologic interventions on biomarkers felt to be relevant to disease pathogenesis. Discovery of effective pharmacotherapy that can prevent disease progression in early-stage COPD has enormous public-health implications, given the current global burden of disease and the proportion of individuals at risk - aging current and former smokers.

Analysis of respiratory sounds: state of the art

OBJECTIVE

This paper describes state of the art, scientific publications and ongoing research related to the methods of analysis of respiratory sounds.

METHODS AND MATERIAL

Review of the current medical and technological literature using Pubmed and personal experience.

RESULTS

The study includes a description of the various techniques that are being used to collect auscultation sounds, a physical description of known pathologic sounds for which automatic detection tools were developed. Modern tools are based on artificial intelligence and on technics such as artificial neural networks, fuzzy systems, and genetic algorithms…

CONCLUSION

The next step will consist in finding new markers so as to increase the efficiency of decision aid algorithms and tools.

Acute enoxaparin treatment widens the therapeutic window for tPA in a mouse model of embolic stroke

OBJECTIVES

The purpose of this experiment was to determine if the low molecular weight heparin (LMWH) enoxaparin could extend the treatment window for thrombolysis in a mouse model of embolic stroke.

METHODS

To establish the treatment window, mice were treated with tPA 2, 3 or 4 hours after clot insertion. Results showed that only the 2 hour treatment group exhibited infarct volumes significantly smaller than untreated controls. We attempted to widen this window by pre-treating mice with enoxaparin (10 mg/kg, s.c.; n=36) 1 hour before embolization. A control group (n=24) was given a saline injection. The enoxaparin-treated animals were subdivided and treated with tPA either 4 (n=12) or 6 hours (n=12) after clot insertion, while the third group (n=12) was given saline. The saline-pre-treated mice were dived into two groups: one group (n=12) received tPA and the other group (n=12) received saline 4 hours post-stroke. Embolization was confirmed by laser Doppler flowmetry and the effects of the resulting infarcts were evaluated by triphenyltetrazolium chloride staining and by behavioral testing.

RESULTS

Results showed large infarcts and impaired sensorimotor coordination in the saline pre-treated animals confirming the narrow treatment window. Enoxaparin pre-treatment produced significantly smaller infarcts and improved motor behavior in groups treated with tPA both 4 and 6 hours after embolization. Neither the 4 nor the 6 hour tPA-treated groups showed evidence of intracerebral hemorrhage or external bleeding.

CONCLUSION

These data indicate that the LMWH enoxaparin can significantly increase the therapeutic time window in a mouse model of embolic stroke.

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

OBJECTIVES

The objective of the review is to determine the efficacy of regular use of inhaled corticosteroids in patients with stable COPD.

SEARCH STRATEGY

A pre-defined search strategy was used to search the Cochrane Airways Group specialised register for relevant literature. Searches are current as of October 2006.

SELECTION CRITERIA

We selected randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short term beta2-agonists and bronchial hyperresponsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. Data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety were also analysed.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Forty-seven primary studies with 13,139 participants met the inclusion criteria. Medium term use of ICS (> two months and up to six months) resulted in a small improvement in FEV1 in some studies. Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients (weighted mean difference (WMD) 5.80 ml/year with ICS over placebo, 95% CI -0.28 to 11.88, 2333 participants). There was no statistically significant effect on mortality in COPD patients (OR 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (WMD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (WMD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.49, 95% CI 1.78 to 3.49, 4380 participants) and hoarseness. The few long term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over 3 years.

AUTHORS' CONCLUSIONS

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life), against the known increase in local side effects (oropharyngeal candidiasis and hoarseness). The risk of long term adverse effects is unknown.

Efficacy and safety of inhaled corticosteroids in patients with COPD: a systematic review and meta-analysis of health outcomes

PURPOSE

We wanted to review systematically the efficacy, effectiveness, and safety of inhaled corticosteroids with respect to health outcomes in patients with chronic obstructive pulmonary disease (COPD).

METHODS

We searched MEDLINE, EMBASE, The Cochrane Library, and the International Pharmaceutical Abstracts to identify relevant articles. We limited evidence to double-blinded randomized controlled trials (RCTs) for efficacy, but we also reviewed observational evidence for safety. Outcomes of interest were overall mortality, exacerbations, quality of life, functional capacity, and respiratory tract symptoms. When possible, we pooled data to estimate summary effects for each outcome.

RESULTS

Thirteen double-blinded RCTs determined the efficacy of an inhaled corticosteroid compared with placebo; 11 additional studies assessed the safety of inhaled corticosteroid treatment in patients with asthma or COPD. Overall, COPD patients treated with inhaled corticosteroids experienced significantly fewer exacerbations than patients taking placebo (relative risk [RR] = 0.67; 95% CI, 0.59-0.77). No significant difference could be detected for overall mortality (RR = 0.81; 95% CI, 0.60-1.08). Evidence on quality of life, functional capacity, and respiratory tract symptoms is mixed. Adverse events were generally tolerable; pooled discontinuation rates did not differ significantly between inhaled corticosteroid and placebo treatment groups (RR = 0.92; 95% CI, 0.74-1.14). Observational evidence, however, indicates a dose-related risk of cataract and open-angle glaucoma. Severe adverse events, such as osteoporotic fractures, are rare; the clinical importance of the additional risk is questionable.

CONCLUSIONS

Overall, the risk-benefit ratio appears to favor inhaled corticosteroid treatment in patients with moderate to severe COPD. Existing evidence does not indicate a treatment benefit for patients with mild COPD.

Enfermedad pulmonar obstructiva crónica

Treatment of chronic obstructive pulmonary disease (COPD) has underwent a very important advance in the last five years. It has been developed a new long-lasting anticholynergic drug, tiotrope bromure, which has been found to improve lung function and exercise capacity and to decrease relapses. Also the combined treatment of long lasting beta 2 adrenergics with inhaled steroids (salmeterol/fluticasone and formoterol/budesonide) has proven similar results. However, the response to these new drugs is not the same in all patients. Individual characteristics such as gravity, degree of bronchial hyperresponsiveness, frequency of relapses, comorbidity, etc will determine the response to several agents. Thus, it is necessary to perform a detailed diagnostic study in COPD patients in order to select the best treatment in an individualized form. In the future, new specific antiinflammatories such as phosphodiesterase 4 inhibitors or agents with a potential action in tissue regeneration could lead to new perspectives, as well as to new questions, in COPD treatment.