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NICE to relax inhaled steroids threshold for COPD patients

By Mark Pownall

Many more patients with COPD will be prescribed an inhaled corticosteroid under new draft NICE guidelines, which relax the threshold at which they are initiated.

The guidance also incorporates the new long-acting muscarinic antagonist and introduces the possibility of triple therapy – long-acting beta agonist (formoterol, salmeterol), long-acting muscarinic agonist (tiotropium) and an inhaled steroid – in patients who have symptoms despite being on single or dual therapy.

The 2004 guidelines stated inhaled corticosteroids should be prescribed for patients with an FEV1 less or equal to 50% predicted – who are having two or more yearly exacerbations needing antibiotics or oral steroids.

But the new guidance simply states anyone with COPD who remains breathless or has exacerbations and an FEV1 less or equal to 50% predicted should start using an inhaled corticosteroid - in a combination inhaler with a LABA.

In addition it builds up the role of spirometry in guiding treatment and says all those managing patients should be comfortable interpreting spirometry measurements.

All health professionals managing COPD patients should have access to spirometry and should be able to interpret results, the new guidance stresses.

It says post-bronchodilator spirometry should be done to confirm diagnosis of COPD and says there may be an alternative diagnosis in older asymptomatic people with an FEV1/FVC ratio below 0.7, or in younger people with symptoms where the ratio is above 0.7.

The age dependent cut-offs are a response to criticism, reported by Pulse, that FEV1 thresholds by themselves are likely to over-diagnose COPD in middle-aged and elderly patients. A Dutch study found false positive rates for spirometry in 43% of patients over 81.

Norfolk GP Professor David Price, professor of primary care respiratory medicine at the University of Aberdeen said: ‘I'm delighted with the move to post bronchodilator FEV1 which brings us in line with the rest of the world and in line with QOF.'

‘I also think the drug therapy changes reflect the evidence and will mean long-acting bronchodilator therapy will be used earlier – with the targeting of inhaled steroid therapy in combination inhalers to milder patients who are most likely to benefit.'

Many more patients with COPD will be prescribed an inhaled corticosteroid under new draft NICE guidelines Many more patients with COPD will be prescribed an inhaled corticosteroid under new draft NICE guidelines

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