Department of Respiratory Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O Box 30.001, 9700 RB Groningen, The Netherlands.
Respir Med. 2011 Dec;105(12):1853-60. doi: 10.1016/j.rmed.2011.07.002. Epub 2011 Jul 29.
The GOLD guidelines advocate not to institute inhaled corticosteroids (ICS) in patients with mild-to-moderate COPD. However, many patients do use ICS and in some patients, withdrawal is associated with deteriorating lung function and increased exacerbation rates. Unfortunately, physicians do not know in which patients they can stop ICS treatment safely.
To identify predictors of COPD exacerbations after ICS withdrawal.
During ICS treatment, post-bronchodilator spirometry, body plethysmography, and health status assessment were performed in 68 COPD patients using ICS. Additionally, sputum cell differentials, supernatant leukotriene B(4), eosinophilic cationic protein, and myeloperoxidase, serum C-reactive protein and soluble intracellular adhesion molecule, and urinary desmosine were assessed. Sputum was also analysed for mRNA levels of haemoxygenase-1, tumour necrosis factor-α, RANTES, interleukin 5(IL-5), IL-10, IL-12, IL-13, transforming growth factor-β, and interferon-γ.
Cox regression analyses were performed using time to exacerbation as outcome variable to identify significant hazards for a COPD exacerbation after ICS withdrawal.
Higher sputum % eosinophils, higher sputum MPO/neutrophil level, longer duration of COPD symptoms, <40 packyears smoking, and ICS withdrawal in November, December or January were significant hazards (all p<0.05) for experiencing a COPD exacerbation after ICS withdrawal in a monovariate model. In a multivariate model, all factors proved independent predictors except for sputum MPO/neutrophil level.
Decisions on whether or not inhaled corticosteroids can be safely withdrawn in mild-to-moderate COPD can be facilitated by assessment of sputum inflammation, particularly eosinophil numbers, next to packyears smoking, season, and duration of COPD symptoms.
GOLD 指南主张在轻度至中度 COPD 患者中不使用吸入性皮质类固醇（ICS）。然而，许多患者确实使用 ICS，并且在某些患者中，停药与肺功能恶化和加重率增加有关。不幸的是，医生不知道在哪些患者中可以安全地停止 ICS 治疗。
确定 ICS 停药后 COPD 加重的预测因素。
在 ICS 治疗期间，对 68 例使用 ICS 的 COPD 患者进行支气管扩张后肺活量测定、体描法和健康状况评估。此外，还评估了痰细胞分类、上清液白三烯 B(4)、嗜酸性阳离子蛋白和髓过氧化物酶、血清 C 反应蛋白和可溶性细胞间黏附分子以及尿脱氧精氨酸。还分析了痰中血红素加氧酶-1、肿瘤坏死因子-α、RANTES、白细胞介素 5(IL-5)、IL-10、IL-12、IL-13、转化生长因子-β和干扰素-γ的 mRNA 水平。
使用时间至加重作为结局变量进行 Cox 回归分析，以确定 ICS 停药后 COPD 加重的显著危害因素。
痰中 %嗜酸性粒细胞较高、痰中 MPO/中性粒细胞水平较高、COPD 症状持续时间较长、吸烟<40 包年、11 月、12 月或 1 月停药是 ICS 停药后发生 COPD 加重的显著危害因素（均 p<0.05）在单变量模型中。在多变量模型中，除了痰 MPO/中性粒细胞水平外，所有因素均为独立预测因子。
通过评估痰炎症，特别是嗜酸性粒细胞数量，以及吸烟包年数、季节和 COPD 症状持续时间，可有助于决定在轻度至中度 COPD 患者中是否可以安全地停用吸入性皮质类固醇。
