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GPs set to take half a million COPD patients off steroid inhalers

GPs are being urged to review all their patients with COPD who are taking inhaled steroids in light of new treatment guidelines, with UK experts estimating that as many as half a million patients who are currently prescribed the inhalers should be taken off them.

Under the new guidelines, from the international Global Initiative for Chronic Obstructive Lung Disease (GOLD) network, GPs should avoid starting patients on inhaled corticosteroid (ICS) therapy unless they have ongoing exacerbations that cannot be controlled with long-acting bronchodilator medications.

This marks a significant shift from previous guidelines, including the NICE guidance on COPD, which advise use of ICS inhalers at an earlier stage, and simply on the basis of poor lung function, experts said.

GOLD board member Professor David Halpin, a consultant respiratory physician at the Royal Devon and Exeter Hospital and former chair of the NICE COPD guidelines, told Pulse this means GPs should review patients at the next opportunity – and that as many as half a million currently on ICS therapy should come off the inhalers.

Professor Halpin said: ‘Studies have shown that up to 40% of patients with COPD are over-treated with ICS, and given the total number of people with COPD a figure of half a million over-treated is a reasonable estimate.’

The changes in treatment recommendations come after publication of a raft of studies finding ICS therapy is less effective and more harmful than previously thought, with side effects such as pneumonia outweighing any benefit for many patients.

GPs in some areas have already come under pressure to take patients off steroids under local cost-cutting measures, but Professor Halpin said these had made only a small impact so far and that GPs should start following the latest GOLD advice because the NICE guidance is now seven years out of date. NICE is currently in the process of updating its recommendations but it is thought the final guidelines will not be available until 2018.

Professor Halpin said: ‘It could potentially be confusing for GPs, but the last NICE update was published in 2010 based on 2009 evidence – that is now seven years out of date, and there have been a lot more studies, so until more up to date NICE guidance is available really people should be looking at the more contemporary guidance.’

He added: ‘At the annual review it would be worth identifying people on inhaled steroids, looking at their exacerbation history and deciding whether there is an indication to continue them and if there isn’t, consider withdrawing it in a controlled manner.’ 

However, GP respiratory experts cautioned that the decision to stop steroid therapy requires very careful assessment – in particular to check for overlapping asthma.

Dr Mark Levy, GPSI in respiratory medicine in North West London, said that while he agreed that the GOLD approach reflected the best evidence-based approach, 'there should be a “health warning” with reducing or stopping inhaled steroids, making 100% sure the person doesn’t have mixed disease with asthma before doing so'.

There are also concerns that GPs still do not have adequate access to the key non-pharmacological alternatives of pulmonary rehabilitation and stop smoking support.

Dr Noel Baxter, chair of the Primary Care Respiratory Society, said the new advice ‘reflects a direction of travel that has been present for a few years now in the UK’ but warned the GOLD guidance ‘is a very long’ and ‘most GPs won’t have time to digest it’.

Dr Baxter said: ‘Locally I would hope COPD interested respiratory specialists and generalists will come together to make a concise and GP relevant guideline using what we now have from GOLD/NICE and our UK respiratory societies.'

Readers' comments (6)

  • Vinci Ho

    (1) Read the thick GOLD guideline last year when it came out . Fundamentally, it is about dividing COPD patients into four groups: those with frequent exacerbations are put aside (group C and D) with or without frequent symptoms. Similar division is made for those with minimal exacerbations(Aand B).
    (2) Hence , inhaled corticosteroids,ICS is only for groups C and D( frequent exacerbation) with mainly the caution of pneumonia related to ICS . Question is how do you practically define 'exacerbation'? Most of the respiratory physicians I talked to ,stick to a textbook definition. But in real life, we also now have a lot of patients on 'rescue packs' in the philosophy of early intervention to avoid hospital admissions. Are they all sensible in using them in so called exacerbation? Fruit of thoughts.
    (3) Incidentally, there have been a mad surge of new inhalers , mainly combined LAMA and LABA preparations, coming into the market in last few years after a very long haul of no new product for COPD. Yes , I know you guys are more than capable of coming up with a conspiracy theory....,,,

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  • Cobblers

    So I need make 100% sure the person doesn’t have mixed disease with asthma?

    Easy one. All COPDs on ICS, unless manifestly Gold C or D, need to be referred to respiratory.

    Can't be too safe! (TFIC)

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  • Thats why we have COPD nurses. Simples!

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  • I have a strange feeling that 95% of my coughing wheezers will turn out to have mixed disease and so will remain on ICS. The 5% we stop will be back in a week saying they "can't stop coughing, doc" all over again. And we'll waste weeks of clinician time to muck about with inhalers while their Lambert & Butler are poking out of their shirt pocket.

    As pointless as it gets.

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  • Hmm didn't realise this was new. Been a long time that I have been doing this several years. Its a good job I don't read NICE guidelines I guess.

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  • In my 25 years as a Gp,most published information on Respiratory medicine could have been written by the 'Grand Old Duke of York'in terms of its longevity.
    Days away from the front line,playing at 'experts'.Meantime punters play it the way they see it.Feeling a bit breathless,better go to A+E must be something new out that the Gp does'nt know about or won't give me.

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