1. Alan Kaplan MD CCFP(EM) FCFP Family Physician Airways Group of Canada
ICS in COPD Withdrawal Tool Abstract
Alan Kaplan MD CCFP(EM) FCFP
Chairperson
Family Physician Airways Group of Canada
Conflicts:
Astra Zeneca, Boehringer Ingelheim,
Novartis, Takeda, Merck Frosst,
Pfizer, Purdue

2. Overuse of ICS in COPD patients classified as GOLD Groups A and B
GOLD Group C
GOLD Group D
ICS here->
13 patients
54% using ICS
604 patients 51% using ICS
GOLD Group A
GOLD Group B
152 patients 33% using ICS
739 patients 38% using ICS
GOLD 2011 criteria were applied to a real-world international COPD population sampled from the Adelphi Respiratory Disease Specific Program, undertaken between June 2011 and September Physicians and patients completed matched questionnaires.2,3
2,392 patients completed a questionnaire, of whom 1508 with all four GOLD classification parameters were analyzed.2,3
The proportion of patients in Groups A, B, C and D when evaluated by CAT was 10%, 49%, 1% and 40%, respectively, and when evaluated by mMRC was 39%, 20%, 13% and 28%, respectively.2
By CAT evaluation, in Groups A, B, C, and D patients were using:
LABA alone (8%, 6%, 0% and 1%)
LAMA alone (37%, 25%, 8% and 5%)
ICS/LABA alone (22% 18%, 8% and 8%),
ICS/LABA plus LAMA (11%, 20%, 46%, 43%), respectively.2
References
GOLD Global Strategy for the Diagnosis, Management and Prevention of COPD, Global initiative for chronic Obstructive Lung Disease (GOLD) Available from:
Small M, S Broomfield, V Higgins, et al. Quantification and Treatment Patterns of Real-World Patients Classified by the GOLD 2011 Strategy. Thorax 2012;67(Suppl. 2):A144–A145 (Abstract P185). Available from:
Higgins V, Broomfield S, Small M. Symptoms, consultations and comorbidities in real-world COPD patients classified by the GOLD 2011 strategy. Presented at COPD8. Birmingham, UK, 20–22 June 2012;(Poster).
Use of ICS (alone or in combination) in patients with COPD by GOLD 2011 group1,2
Data were drawn from the Adelphi Respiratory Disease Specific Programme, a large multinational (France, Germany, Italy, Spain, UK, USA) cross-sectional survey generating real-world data based on actual clinical practice. N=15082,3
1. GOLD 2013, 2. Small et al. BTS 2012 Abstract, 3. Higgins et al. COPD Abstract 2

3. Do ICS work?

4. What about Mortality?

5. Side effects of ICS in COPD and type of evidence
Randomised controlled trial
Observational study
Systematic review
Pneumonia X
Tuberculosis
Bone fracture
(no effect on fracture risk)
Skin thinning/ easy bruising
Cataract
Diabetes
Oropharyngeal candidiasis
Price D. Prim Care Respir J 2013; 22:

6. Wisdom

7. Estimated probability of moderate or severe COPD exacerbation
0.6
Hazard ratio, 1.06 (95% CI, 0.94–1.19)
P=0.35 by Wald’s chi-squared test
0.5
0.4
0.3
Estimated probability
0.2
ICS ICS withdrawal
0.1
0.0 6 12 18 24 30 36 42 48 54
Time to events (weeks)
No. at risk ICS
ICS withdrawal
646
14 19
Magnussen H et al. N Engl J Med DOI /NEJMoal407154

9. Time to first severe and any severity on-treatment COPD exacerbation
0.975
1.202
1.482
Time to first
COPD exacerbation
(any severity)
Hazard ratio
Favours withdrawal
Favours ICS
On-treatment exacerbations assessed; hazard ratio from Cox proportional hazards model adjusted for baseline FEV1
Magnussen H et al. N Engl J Med DOI /NEJMoal407154

10. Mean change from baseline in lung function: FEV1
ICS withdrawal
250 µg BID
100 µg BID
0 µg (placebo)
Week
38 mL
ICS
Adjusted mean (SE) change from baseline in FEV1 (mL)
43 mL
ICS withdrawal
***
SE, standard error **
n ICS withdrawal ICS
**p<0.01; ***p< vs ICS; restricted maximum likelihood repeated measures model; baseline values 970 mL for ICS, 981 mL for ICS withdrawal
Magnussen H et al. N Engl J Med DOI /NEJMoal407154

11. So, NOT for ALL of our COPD patients, Certainly not the ACOS patients

12. Do eosinophils predict response to ICS beyond exacerbations
Do eosinophils predict response to ICS beyond exacerbations? Chiesi data:
| QVA Update | Robert Fogel | Canada Advisory Board, Sep 26, 2015 |Business Use Only | Material ID Code:

13. Is this whole idea worth the trouble? Well, these are OUR patients!

14. How to take patients off ICS? ICS in COPD withdrawal tool
Kaplan A. Applying the WISDOM of Stepping Down Inhaled Corticosteroids in Patients with COPD:
A Proposed Algorithm for Clinical Practice. Int J COPD

15. Risk of recurrent pneumonia rises with current ICS use, not linked to past ICS use
Eurich DT et al. Clin Infect Dis. 2013; 57 (8):

17. Are they eligible for ICS withdrawal?

18. If no reason they should stay on ICS...

19. Questions for you? Do you agree this is an issue?
Do you think that it is too complicated?
Do you think there are too many steps?
Or should we just stop the ICS cold?

20. www.fpagc.com for4kids@gmail.com Comments on the tool?
I would LOVE to hear them!!!!