ICS overuse warning in COPD

Nov 11 2013

Researchers from the UK caution that inhaled corticosteroids (ICS) are being overused in patients with chronic obstructive pulmonary disease (COPD), in light of a lack of solid evidence for their efficacy, limited guideline support, and growing concerns over their association with pneumonia.

Patrick White (Kings College London) and colleagues analyzed data from general practices on 2458 patients with COPD between December 2009 and November 2010.

At that time, the current 2009 guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stated that ICS should only be used to prevent exacerbations in patients with severe disease and a history of frequent disease.

Among the 1749 patients with spirometry-confirmed disease, 59.8% were prescribed inhaled medication in accordance with this guidance, 8.6% were undertreated, and 37.7% were overtreated for their GOLD stage. And, of the 659 overtreated patients, 96.2% of those without concomitant asthma were overtreated with an ICS.

The team notes that overtreatment was more likely in patients with mild disease and undertreatment increased with severity. For example, among patients with stage I disease, 46.3% were overtreated and none were undertreated. By comparison, 28.8% of stage IV patients were overtreated, and 14.4% were undertreated.

In multivariate analysis, the odds for overtreatment significantly associated with Medical Research Council Dyspnoea Score, with patients with a score of 5 having a 2.1-fold greater odds than those with a score of 1 or 2. Meanwhile, having had an exacerbation in the past 2 years was associated with a 65% lower odds for overtreatment.

The most recent GOLD guidelines, updated in 2011, now include a recommendation for ICS treatment in patients with severe or very severe COPD, even if they have not had an exacerbation in the previous year. According to this definition, the overall proportion of overtreatment would reduce to 24%, the authors report, but the proportion of undertreatment would increase.

“Over-prescribing of ICS in COPD has been reported in a number of countries,” comment White et al in PLoS One.

“Factors underlying this may be the perceived similarity of COPD and asthma, the common occurrence of the two diseases together, and a hope that steroids could reduce the impact of symptoms in COPD.”

However, they note that this situation has not been helped by the presence of conflicting guidelines, based around ambiguous data.

“A balanced assessment… would help clinicians to weight up the risks and benefits of treatment for a progressive condition such as COPD where treatment is often escalated in the hope of easing the increasing burden of disease,” they conclude.

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