Are We Overtreating Stage B COPD?
Kooblall M, McCarron R, Burke CM
Respiratory Department, Connolly Hospital, Dublin 15
A patient with stage B COPD is defined as having a mMRC dyspnoea score of greater or equal to 2 (or CAT score greater or equal to 10), up to one exacerbation not leading to hospital admission and having a FEV1 greater than 50 % predicted. The recommended treatment as per the GOLD guidelines is to use either a long acting muscarinic agent (LAMA) or a long acting beta agonist (LABA) or a combination of both LAMA and LABA1
A charts review was performed from the COPD outreach database at Connolly hospital. Out of 330 charts reviewed, 24 (7%) patients were found to have stage B COPD based on the GOLD guidelines.
Out of these 24 patients 6(25%) were males and 18(75%) were females and they were aged between 48 and 85 years old. Nineteen (79%) patients with stage B COPD on inhaled steroids mostly on combination inhalers. Two (8%) patients had a mixed asthma/copd diagnosis. Seven (29%) patients were on LABA and LAMA combination.
An issue of potential concern with the use of such combination treatments with inhaled steroid is an associated increased risk of pneumonia. A large observational study identified a dose related association between inhaled corticosteroid and an increased incidence of admissions to hospital related to pneumonia and mortality in older patients with COPD. In randomised controlled trials, fluticasone alone or in combination with salmeterol has been linked with increases in the incidence of pneumonia compared with alternative bronchodilator regimens. In the TORCH trial, the absolute risk of pneumonia with salmeterol/fluticasone also increased with GOLD stage2.
In Ireland, over 400,000 people are estimated to have COPD and there are still many undiagnosed3. Reflecting on the findings from the charts review, we can conclude that patients with stage B COPD are currently being overtreated with inhaled steroid which have been shown to have adverse effect.
Minesh Kooblall, Connolly Hospital, Blancardstown, Dublin 15
1. http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html (accessed 21 february 2016)
2. Janson C, Larsson K, Lissper KH, Stallberg B, Stratelis G, Goike H, Jorgensen L, Johansson L..Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting β2 agonist: observational matched cohort study (PATHOS). BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3306 (Published 29 May 2013) Cite this as: BMJ 2013;346:f3306
3. RCPI Medical Workforce planning Feb 2014;196