Healthcare professionals should ‘propose a personalised approach to escalating/de-escalating treatment based on the level of symptoms and the individual’s risk of exacerbations’ in COPD, according to the 2017 edition of GOLD guidance for the disease.
It advises that bronchodilator and dual bronchodilator therapy should be the first-line treatment for the vast majority of COPD patients and only those with severe risk of exacerbations should be taking inhaled corticosteroids.
Clinicians should consider withdrawing inhaled steroids if the patient does not have a history of exacerbations, is experiencing harmful side effects, or if there is no evidence of benefit - although this should be done with caution - the advice says.
GP respiratory care
GP experts said the updated advice could have huge consequences for clinical practice in the UK, with scores of patients per practice list potentially given unnecessary steroids ‘for years’.
The GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidance does not make UK-specific recommendations, but is largely adopted in the UK due to being updated annually. NICE guidelines on COPD were last updated six years ago in 2010 and will not be updated again until late 2017.
The de-emphasis on inhaled steroids comes as a spate of long-term studies released in the last year suggested the treatment offered 'limited' benefit in COPD patients.
‘Traditionally, it’s been about adding more treatments; this is the first time it’s recommended to consider stepping down,’ said Dr Vincent McGovern, a GPSI in COPD, speaking at a briefing funded by Boehringer Ingelheim.
‘The reasons for this are A) the patient shouldn’t have been on it in the first place, B) the risk of side effects such as pneumonia and C) they are taking them for exacerbations but it’s having no effect.'
According to the GOLD guidance, management of COPD should depend on an individualised assessment of a patient’s symptoms and their risk of exacerbations.
Symptomatic patients, exacerbating patients and those with both all have different recommended courses of treatment.
The guidance uses an ABCD system – which has received ‘major’ updates in the latest advice – to categorise patients. Patients are rated A, B, C or D based on the severity of their symptoms and their history of exacerbations.
Groups A and B represent patients with low risk of exacerbations and progressively worse symptoms, and C and D those with a severe risk of exacerbations and minor or major symptoms, respectively.
Changes to the definition of ABCD means that many patients will now have been downgraded from group D to group B, experts said – meaning their treatment recommendations have changed.
‘This is a big change – a lot of patients have moved into groups A and B under the new definitions in the guideline,’ said Dr McGovern. ‘GOLD says if you're in groups A or B – that’s 50% of the GP population – with no exacerbation, then you shouldn’t be on inhaled steroids.
‘The message to primary care is that COPD is not asthma and its management is different. Every asthma patient starts on a steroid, but that should be different for COPD – it’s not the same. Inhaled steroids only come in if they have a history of exacerbations.’
The guidance stresses that non-pharmacological therapies are also very important for managing the condition, and all patients should be advised on smoking cessation, inhaler technique and exercise.