Response

Abstract

We appreciate Lipworth et al for their thoughtful response to our article regarding the safety and effectiveness of inhaled corticosteroids and long-acting β2 agonists (ICS/LABA) combinations in COPD management.1Chang T.Y. Chien J.Y. Wu C.H. Dong Y.H. Lin F.J. Comparative safety and effectiveness of inhaled corticosteroids and long-acting β2-agonist combinations in patients with COPD.Chest. 2020; 157: 1117-1129Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Due to the lack of modified Medical Research Council or COPD Assessment Test score recorded in the administrative database, we could not properly classify our study population into severity groups according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) ABCD assessment tool. However, we agree that most patients belonged to GOLD group A or B because approximately 85% of them did not experience severe acute exacerbation (AE) (ie, leading to hospital or emergency room admission) in the previous year (not 97% as stated by Lipworth et al).1Chang T.Y. Chien J.Y. Wu C.H. Dong Y.H. Lin F.J. Comparative safety and effectiveness of inhaled corticosteroids and long-acting β2-agonist combinations in patients with COPD.Chest. 2020; 157: 1117-1129Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar We did wonder if frequent exacerbators were more susceptible to severe pneumonia after certain ICS use; thus, we performed a stratified analysis by severe AE history to clarify this issue. Actually, we found that the increased risk of severe pneumonia associated with fluticasone propionate/salmeterol dry-powder inhaler or metered-dose inhaler was less pronounced in patients with a history of severe AE (GOLD group C or D), compared with those without (GOLD group A or B). However, the findings should be interpreted cautiously owing to the much smaller sample size in the subgroup with a history of severe AE. Furthermore, the discussions related to the level of blood eosinophils and prediction of treatment response are interesting and important. The level of blood eosinophils may be a promising surrogate marker of airway eosinophilic inflammation to guide the treatment decision of ICS therapy in COPD; patients with higher blood eosinophil counts have been shown to benefit more with the use of ICS/LABA in reducing exacerbation rate.2Pavord I.D. Lettis S. Locantore N. et al.Blood eosinophils and inhaled corticosteroid/long-acting beta-2 agonist efficacy in COPD.Thorax. 2016; 71: 118-125Crossref PubMed Scopus (257) Google Scholar,3Pascoe S. Locantore N. Dransfield M.T. Barnes N.C. Pavord I.D. Blood eosinophil counts, exacerbations, and response to the addition of inhaled fluticasone furoate to vilanterol in patients with chronic obstructive pulmonary disease: a secondary analysis of data from two parallel randomised controlled trials.Lancet Respir Med. 2015; 3: 435-442Abstract Full Text Full Text PDF PubMed Scopus (530) Google Scholar Yet, laboratory data were not available in the administrative database; therefore, we were not able to study this issue or control for the level of blood eosinophils in the analysis. We expect to see more future studies that will determine the optimal utility of blood eosinophils in clinical practice and assess the comparative risk and benefits of different ICS/LABA combinations while taking blood eosinophil counts into consideration. Pneumonia Due to Inhaled Corticosteroids in COPDCHESTVol. 157Issue 6PreviewWe read with interest in a recent issue of CHEST (May 2020) the real-life health informatics data of Chang et al1 from Taiwan that showed a significantly lower risk of severe pneumonia between budesonide/formoterol and fluticasone propionate/salmeterol dry powder inhalers, which amounted to an 18% (95% CI, 2 to 31%) difference with adjustment for therapeutically equivalent doses.1 The more prolonged lung retention of fluticasone propionate than budesonide in the presence of altered microbiome and impaired mucociliary clearance results in a greater propensity for inducing pneumonia in COPD as a consequence of inhaled corticosteroid-related immunosuppression. Full-Text PDF Comparative Safety and Effectiveness of Inhaled Corticosteroid and Long-Acting β2-Agonist Combinations in Patients With COPDCHESTVol. 157Issue 5PreviewThe differential risk of pneumonia among inhaled corticosteroid (ICS) use in patients with COPD requires more investigation, especially regarding beclomethasone-containing inhalers. The goal of this study was to compare the risk and benefit profile of different ICS/long-acting β2-agonist (LABA) combinations in patients with COPD. Full-Text PDF