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Intensified Therapy with Inhaled Corticosteroids and Long-Acting β2-Agonists at the Onset of Upper Respiratory Tract Infection to Prevent Chronic Obstructive Pulmonary Disease Exacerbations. A Multicenter, Randomized, Double-Blind, Placebo-controlled Trial

Author(s): Daiana Stolz, Hans H. Hirsch, Daniel Schilter, Renaud Louis, Janko Rakic, Lucas Boeck, Eleni Papakonstantinou, Christian Schindler, Leticia Grize, Michael Tamm

Am J Respir Crit Care Med. 2018; 197: 1136-1146

Airway diseases
Respiratory critical care
Respiratory infections

Digest Author(s): Julien Guiot / 12 March, 2019

In chronic obstructive pulmonary diseases (COPD), inhaled corticostéroids (ICS) are associated with side-effects including risk of pneumonia. International recommendations propose inhaled corticosteroids only in cases of patients with frequent exacerbations despite optimal bronchodilator therapy. In addition, multiple studies have demonstrated the positive impact of ICS in patients with significant eosinophilia in blood or lung.

In this study Stolz et al. explore the potential positive impact of high dose of ICS in upper respiratory tract infection to prevent COPD exacerbation. They identify that an intensified dose of ICS/LABA during 10 days was reducing by 72% the risk of severe exacerbation. Moreover, the treatment seems to be safe and well tolerated. Nevertheless, the treatment didn’t decrease the overall risk of exacerbation compared with placebo (14.6 vs 16.2%). Effect were also modified by disease severity as well as by fractional exhaled nitric oxide (FeNO), and the BODE index.

The authors aknowledge that the relatively small number of patients limited the potential impact of the results (with low number of events).

This study oppens the potential usefulness of ICS to prevent severe exacerbations in all COPD patients and any exaerbations in patients with more severe disease.

Key points :

  • Intensified combination therapy with ICS/LABA for 10 days at URTI onset did not decrease the incidence of any COPD exacerbation but prevented severe exacerbation.
  • The benefit of high doses of ICS during exacerbation has to be explored in further longitudinal studies in the particular case of severe COPD.
  • Nowadays, the optimal dose of ICS is still not determined and has to be evaluate in order to balance the risk and benefit of these treatments in ICU.