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COPD - Case study

Changes/additions to materials (reviewed 11/04/11):

Inhaled corticosteroids and the risk of diabetes

A Canadian cohort study identified that patients treated for respiratory disease using inhaled corticosteroids (ICS) over a period of 5.5 years were, on average, at a 34% increased risk of both diabetes onset and diabetes progression compared with patients not treated with ICS. The risk increased with increasing dose of ICS. Patients treated with high doses of ICS, equivalent to fluticasone 1000microgram/day or more, had, on average, a 64% increased risk of developing diabetes compared with patients not treated with ICS.

Prescribers should follow the British guideline for the management of asthma with regard to the use of ICS in patients with asthma. The dose of ICS should be titrated to the lowest dose at which effective control is maintained. In COPD, ICS should be used only in combination with a long-acting beta-agonist and only in accordance with the NICE guideline for COPD. See MeReC Rapid Review No. 2485 for more details.

New NICE guidance on COPD

Since these materials were published NICE has published a new clinical guideline on the management of COPD in adults in primary and secondary care (CG101). This guideline partly updates and replaces the previous guidance (CG12).

CFC-containing inhalers

The last remaining stocks of CFC-containing pharmaceutical metered dose inhalers are now rapidly depleting. Any patients who are still prescribed these products will need to be switched to a suitable alternative as quickly as possible. Please see Rapid review No.1380 for more information, including links to useful resources to help manage the changeover.

Possible safety concerns with inhaled anticholinergics

The November 2008 edition of Drug Safety Update highlighted new data on the risk of death or stroke with inhaled anticholinergics. As we reported in Rapid review No. 205 and No. 223, there is some evidence to suggest that inhaled anticholinergic drugs (ipratropium, tiotropium) increase the risk of cardiovascular events in people with chronic obstructive pulmonary disease (COPD) compared with placebo or active comparators (inhaled corticosteroids and/or beta-agonists). However, no such increased risk was demonstrated in the UPLIFT study. As we state in Rapid review No. 235, because of the uncertainty, it is difficult to draw firm conclusions on the risk associated with inhaled anticholinergics. Drug Safety Update concludes that further analyses are needed to shed light on any increased risk, and recommends that patients who take tiotropium for COPD should not exceed the recommended dose.

A MeReC Bulletin on COPD is now available

The Bulletin reviews a number of safety concerns which have emerged relating to inhaled treatments for COPD, and sets them into the context of the potential benefits these treatments have. For example:

• The benefits of long-acting bronchodilators and inhaled corticosteroids for patients with COPD
• The safety issues with long-acting beta2 agonists (LABAs) in COPD
• The safety issues with anticholinergics in COPD
• The safety issues with inhaled corticosteroids in COPD
• What needs to be considered when treatment choices are made.