Cochrane for Clinicians

Putting Evidence into Practice

Use of Inhaled Corticosteroids to Treat Stable COPD

william e. cayley jr, MD, University of Wisconsin Department of Family Medicine, Eau Claire, Wisconsin

Clinical Scenario

A 60-year-old patient with a 40 pack-year smoking history requests "something else" to treat his chronic cough and dyspnea from chronic obstructive pulmonary disease (COPD). He is already using an albuterol/ipratropium (Combivent) inhaler as needed.

Clinical Question

Should inhaled corticosteroids be used to treat stable COPD?

Evidence-Based Answer

Although the use of inhaled corticosteroids for COPD will not reduce mortality or affect long-term disease progression, inhaled corticosteroids can be useful for reducing COPD exacerbations and slowing declines in quality of life.

Practice Pointers

Recent guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD)1 and the American College of Physicians (ACP)2 have addressed the management of stable COPD and recommend attention to four areas for individualized management of COPD: disease monitoring, risk factor reduction, management of stable COPD, and management of acute exacerbations. GOLD recommends long- and short-acting bronchodilators for day-to-day symptom control, with the addition of an inhaled corticosteroid for symptomatic patients with a forced expiratory volume in one second (FEV1) less than 50 percent of predicted volume.1

In contrast, the ACP recommends long-acting inhaled beta-agonists, long-acting inhaled anticholinergics, and inhaled corticosteroids as equally beneficial in reducing exacerbations. The ACP notes that bronchodilators and inhaled corticosteroids are similar in overall effectiveness, but differ somewhat in rates of adverse effects, reductions in hospitalizations, and mortality. The ACP recommendations for management of COPD are listed in the accompanying table.2

This Cochrane review provides additional clarification on the role of inhaled corticosteroids in COPD management.3 Inhaled corticosteroids do not appear to slow declines in the measures of lung function or to reduce rates of mortality from COPD, but they do appear to reduce the frequency of COPD exacerbations and to reduce declines in the measures of quality of life. The primary drawbacks to inhaled corticosteroids for COPD are local side effects and the lack of information on potential long-term adverse effects. Use of inhaled corticosteroids increases the risks of oropharyngeal complications, including hoarseness and oral candidiasis, although the latter may be avoidable with proper rinsing of the mouth after dosing. Currently, there is inadequate evidence to tell whether inhaled corticosteroids may reduce bone density, increase fractures, or cause other metabolic derangements over long-term (i.e., more than three years) therapy.

Because none of the available medications for COPD are able to modify long-term declines in lung function, individual treatment should be selected based on disease severity and the relative benefits and complications of different therapies. The lack of information on long-term adverse effects from inhaled corticosteroids may warrant caution in initiating inhaled corticosteroids for younger patients with less severe disease. Conversely, the benefit of inhaled corticosteroids to older patients with more severe disease may outweigh the potential for long-term adverse effects. In either case, patient education on proper inhaled corticosteroid use is important to help reduce the likelihood of local side effects.

Address correspondence to William E. Cayley Jr, MD, at bcayley@yahoo.com. Reprints are not available from the author.

Author disclosure: Nothing to disclose.

REFERENCES

1. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532-555.

2. Qaseem A, Snow V, Shekelle P, et al., for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;147(9):633-638.

3. Yang IA, Fong KM, Sim EHA, Black PN, Lasserson TJ. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007;(2):CD002991.

Cochrane Briefs

Low Glycemic Diets for Obesity Treatment

Clinical Question

Are low glycemic index or low glycemic load diets effective in the treatment of obesity?

Evidence-Based Answer

Compared with high glycemic index diets or conventional energy-restricted weight loss diets, low glycemic index diets better reduce body mass index (BMI) and low-density lipoprotein (LDL) cholesterol. The weighted mean difference showed that patients lost an additional 1 to 2 BMI units on the low glycemic index diets.

Practice Pointers

There are a number of treatments for obesity that have been proven effective, especially over the short term. Behavior and cognitive behavior therapy are effective, especially when combined with diet and exercise.1 Surgery results in greater weight loss than conventional treatments and improves quality of life, hypertension, and diabetes. However, it has a significant risk for morbidity and mortality.2 There is some evidence that anti-obesity agents such as orlistat (Xenical) and sibutramine (Meridia) promote weight loss, but studies have had methodological problems.3 Exercise and diet are effective. Exercise improves cardiovascular disease risk factors even when participants do not lose weight.4 Fat-control and calorie-control diets achieve weight loss.5

In this review, low glycemic index diets have been shown to be more effective than low-calorie or higher glycemic index diets. The authors found six randomized controlled trails (N = 202). Study interventions were at least five weeks. The longest studies had a six-month intervention with a six-month follow-up. No studies reported on adverse effects, mortality, or quality of life. Compared with other diets, low glycemic index diets resulted in statistically and clinically significant reductions in BMI, LDL cholesterol, and total fat mass. There was a reduction in insulin resistance, but not fasting morning insulin. Longer-term studies on treatment for obesity are needed.

clarissa kripke, MD

Source: Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database Syst Rev. 2007;(3):CD005105.

Author disclosure: Nothing to disclose.

REFERENCES

1. Shaw K, O'Rourke P, Del Mar C, Kenardy J. Psychological interventions for overweight or obesity. Cochrane Database Syst Rev. 2005;(2):CD003818.

2. Colquitt J, Clegg A, Loveman E, Royle P, Sidhu MK. Surgery for morbid obesity. Cochrane Database Syst Rev. 2005;(4):CD003641.

3. Padwal R, Li SK, Lau DC. Long-term pharmacotherapy for obesity and overweight. Cochrane Database Syst Rev. 2003;(4):CD004094.

4. Shaw K, Gennat H, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev. 2006;(4):CD003817.

5. Pirozzo S, Summerbell C, Cameron C, Glasziou P. Advice on low-fat diets for obesity. Cochrane Database Syst Rev. 2002;(2):CD003640.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 1507.

The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.