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NICE steroids advice for COPD thrown into doubt

Inhaled steroids can slow lung function decline in all patients with chronic obstructive pulmonary disease, reveals a US Government-funded study.

The finding challenges the traditional view that the drugs only benefit the most severe COPD patients. It also casts doubt on a provisional ruling by the National Institute for Clinical Excellence that using inhaled steroids in mild COPD is an 'unnecessary cost'.

NICE has criticised the fact that up to 70 per cent of COPD patients are taking an inhaled steroid, claiming there is 'no rationale' to support prescribing in many cases.

The new meta-analysis, published in Thorax (November), found low-dose inhaled steroids reduced the rate of FEV1 decline by an average of 7.7ml/year and high-dose steroids by 9.9ml/year.

In patients with a baseline FEV1 of less than 50 per cent predicted, the reduction in decline was 18.3ml/year.

Study co-author Dr Andrea Venn, lecturer in epidemiology at the University of Nottingham, said inhaled steroids brought about a relative reduction in rate of lung function decline of 13-17 per cent in smokers and 26-33 per cent in non-smokers with COPD.

She added: 'Although the numerical effect is small, inhaled steroids do have a moderate relative effect and may supplement other interventions such as smoking cessation in modifying the natural history of the disease.'

Dr Sherwood Burge, consultant respiratory physician at Birmingham Heartlands Hospital ­ whose commentary on the study was published in Thorax ­ said it was 'unethical' to continue questioning the validity of using inhaled steroids in COPD. He added: 'The optimal dose is still unknown. On current evidence doses of beclomethasone or equivalents of up to 800-µg/day should be used. Any increased benefit for higher doses remains to be proven.'

But Professor David Price, professor of primary care respiratory medicine at the University of Aberdeen and a GP in Norwich, was 'very surprised' by the findings.

He said: 'This runs counter to what the individual studies have shown. If it's true it is of major importance. My main issue would be with generalising the results. We need to look at the data in detail and see exactly how it should be applied in clinical practice.'

The NICE draft guidelines on COPD, due to be finalised in February, tell GPs to limit inhaled steroids to COPD patients with an FEV1 of less than or equal to 50 per cent.

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