A proposal for the withdrawal of inhaled corticosteroids in the clinical practice of chronic obstructive pulmonary disease.

According to the current clinical practice guidelines for chronic obstructive pulmonary disease (COPD), the addition of inhaled corticosteroids (ICS) to long-acting ß2 agonist therapy is recommended in patients with moderate-to-severe disease and an increased risk of exacerbations. However, ICS are largely overprescribed in clinical practice, and most patients are unlikely to benefit from long-term ICS therapy.Evidence from recent randomized-controlled trials supports the hypothesis that ICS can be safely and effectively discontinued in patients with stable COPD and in whom ICS therapy may not be indicated, without detrimental effects on lung function, health status, or risk of exacerbations. This article summarizes the evidence supporting the discontinuation of ICS therapy, and proposes an algorithm for the implementation of ICS withdrawal in patients with COPD in clinical practice.Given the increased risk of potentially serious adverse effects and complications with ICS therapy (including pneumonia), the use of ICS should be limited to the minority of patients in whom the treatment effects outweigh the risks.

Management and referral of patients with severe and poorly controlled asthma in primary care.

BACKGROUND: Over 50% of treated patients with asthma in Europe are not well controlled. Their management in primary health care (PHC) differs from that in specialized care, and there is no real coordination between the two. OBJECTIVES: To identify barriers and solutions to improving the management of patients with severe and poorly controlled asthma and the communication between specialists and PHC, and to reach a consensus on the criteria for referral patients. METHODS: An observational study using a modified Delphi technique. About 79 physicians from PHC, pneumology and allergy fields from different Spanish regions were invited to participate via an online questionnaire. Consensus was reached on an item when more than two-thirds of the panel members scored within the 3-point category (1-3 or 7-9) containing the median and the interquartile range of answers had to be ≤4 points. RESULTS: Response rate: 52%. After the second round, consensus items were 40 (62.5%): of which 37 in agreement and 3 in disagreement. Around 92.68% of respondents agreed that it would be useful to incorporate questionnaires for asthma control into PHC computer-based searches. About 100% of participants agreed that clear consensus criteria between PHC and specialists must be determined to decide when a patient with asthma is referred from PHC to specialist or vice versa. Ten of the proposed criteria reached consensus agreement. CONCLUSION: The failure to use guidelines and specific questionnaires for asthma control in PHC is one reason why there is underdiagnosis and poor control of asthma. Some strategies to improve the asthma care management emerged from the survey results.

[External assessment of the GEMA2009 recommendations by a multidisciplinary expert panel on asthma]. / Valoración externa de las recomendaciones de la GEMA2009 por un panel multiprofesional de expertos en asma.

OBJECTIVES: To assess the level of agreement on the GEMA 2009 clinical recommendations by a Spanish expert panel on asthma. MATERIALS AND METHODS: The study was divided into four stages: 1) establishment of a 9 member scientific committee (GEMA authors) for selection of GEMA recommendations to use in the survey; 2) formation of a panel of 74 professionals with expertise in this field (pulmonologists, allergists, family doctors, ear, nose and throat and paediatric specialists); 3) Delphi survey in two rounds, sent by mail, with intermediate processing of opinions and a report to the panel members; and 4) analysis and discussion of results for the Scientific Committee. RESULTS: Seventy four participants completed the two rounds of survey. During the first round, a consensus was reached in 49 out of 56 questions analysed. Following discussion by the panel, the consensus was increased to a total of 53 items in the survey. With respect to the remaining questions, Insufficient consensus was obtained on the rest of the questions, due to differing views between sub-specialists, or lack of criteria by most of the experts. CONCLUSIONS: The external analysis by asthma experts from different specialities showed a high level of professional agreement with the GEMA 2009 recommendations in Spain (96.5%). The disagreement shown in three recommendations reflect the lack of a high level evidence. These issues represent areas of interest for future research.