Arguments Against Inhaled Glucocorticoids in COPD by Phenotype Instead of by Severity

Abstract

Before entering into the debate created by the title proposed by the Editorial Committee of Archivos de Bronconeumologia, I believe it is essential to establish three previous considerations. The first is in reference to the use of glucocorticoids in stable COPD. Currently, and after the results of the Towards a Revolution in COPD Health (TORCH)1 assay, it is difficult to recommend their continuous use in an isolated manner (monotherapy) without associating at least one long-acting beta-agonist bronchodilator, either separately or combined in the same device. From the perspective of therapeutic efficacy as well as from that of safety, the TORCH assay shows that the combination of an inhaled glucocorticoid with a long-acting beta-agonist is always better than the individual use of these two components. The second consideration is the term “phenotype”, understood as those structural and functional characteristics observed in an organism that aremodulated by interaction with the genotype and setting.2 The third and last is the word “severity”, which in stable COPD should be contextualized within the framework of the clinical data and the spirometric anomalies. Having set these three premises, I will center the debate within the context of the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD). Starting with the first version of the Executive Summary in 20013 and later in the second from 2007,4 the GOLD proposal has coherently defended a series of suggestions related with the management and treatment of stable COPD. These are based on the principle that the clinical approach and pharmacologic treatment of COPD (aside from exacerbations) are characterized by a staggered increase of the medication depending on the severity of the disease and its response to the individual therapeutic possibilities of each patient. And it indicates that the severity of the disease is determined by the relevance of the symp-