From the Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada (AGK)
J Am Board Fam Med. 2020 Mar-Apr;33(2):289-302. doi: 10.3122/jabfm.2020.02.190227.
Inhaled corticosteroid (ICS)-based therapy is often used for patients with chronic obstructive pulmonary disease (COPD). However, this approach is under scrutiny because of ICS overuse in patients for whom it is not recommended and because of concerns about adverse events, particularly pneumonia, with long-term ICS use. Evidence suggests ICS may be beneficial in specific patients, namely, those with high blood eosinophil counts (eg, ≥300 cells/µL) or who are at a high risk of exacerbations. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 ABCD assessment tool, these patients belong in group D. For these patients, recommended initial treatment includes ICS in combination with long-acting β2-agonists (LABAs) when blood eosinophil counts are ≥300 cells/µL or LABA + long-acting muscarinic antagonist (LAMA) when patients are highly symptomatic, that is, with greater dyspnea and/or exercise limitation. Follow-up treatments for patients with persistent dyspnea and/or exacerbations may include LABA + ICS, LABA + LAMA, or LABA + LAMA + ICS, with use of ICS being guided by blood eosinophil counts. In this review, differences in the inflammatory mechanism underlying COPD and asthma and the role of ICS treatment in COPD are summarized. Furthermore, findings from recent clinical trials where use of ICS-based dual or triple therapy in COPD was compared with LABA + LAMA therapy and trials in which ICS withdrawal was evaluated in patients with COPD are reviewed. Finally, a step-by-step guide for ICS withdrawal in patients who are unlikely to benefit from this treatment is proposed. A video of the author discussing the overall takeaway of the review article could be downloaded from the link provided: https://www.youtube.com/watch?v=Uq7Sr5jqPDI.
吸入性皮质类固醇（ICS）疗法常用于治疗慢性阻塞性肺疾病（COPD）患者。然而，由于ICS 在不推荐使用的患者中过度使用，以及长期使用 ICS 可能会引起不良反应（尤其是肺炎），因此这种方法受到了质疑。有证据表明，ICS 可能对特定患者有益，即那些血嗜酸性粒细胞计数较高（例如，≥300 细胞/µL）或有较高恶化风险的患者。根据全球慢性阻塞性肺疾病倡议（GOLD）2020 年 ABCD 评估工具，这些患者属于 D 组。对于这些患者，建议的初始治疗包括在血嗜酸性粒细胞计数≥300 细胞/µL 时使用 ICS 联合长效β2-激动剂（LABA），或者在患者症状严重（即呼吸困难和/或运动受限更严重）时使用 LABA +长效抗胆碱能药物（LAMA）。对于持续呼吸困难和/或恶化的患者，后续治疗可能包括 LABA + ICS、LABA + LAMA 或 LABA + LAMA + ICS，使用 ICS 则取决于血嗜酸性粒细胞计数。在这篇综述中，总结了 COPD 和哮喘的炎症机制差异以及 ICS 治疗在 COPD 中的作用。此外，还回顾了最近的临床试验，这些试验比较了 COPD 中 ICS 联合双药或三联疗法与 LABA + LAMA 疗法的疗效，以及评估了 COPD 患者中 ICS 停药的试验。最后，提出了一个针对不太可能从这种治疗中获益的患者的 ICS 停药的逐步指导。可以从提供的链接下载作者讨论综述文章总体要点的视频：https://www.youtube.com/watch?v=Uq7Sr5jqPDI。
