The American Thoracic Society guideline for managing patients with chronic obstructive pulmonary disease

Référence

Nici L, Mammen MJ, Charbek E, et al. Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med 2020;201(9):e56-e69.

Sommaire

The ATS convened a guideline development panel composed of a methodology team and a team of experts. Although the co-chairs of the teams and at least 50% of the panel members had to be free of conflicts of interest, many panel members reported ties to industry. They chose not to include patients on the panel because of some nonsense excuse that clinically active "experts" can infer patient value preferences. Otherwise, the panel used explicit approaches to identify key clinical questions, conduct systematic reviews, assess the risk of bias of included studies, construct evidence tables, and assess the safety and effectiveness of interventions. To compare dual therapy (LABA plus LAMA) with monotherapy, they found 24 randomized controlled trials with 45,441 participants that demonstrated the combination of LABA plus LAMA improved symptom scores and reduced exacerbations and hospitalizations more than monotherapy without an increase in adverse events. For patients with dyspnea or exercise intolerance despite dual therapy, the panel identified 4 randomized controlled trials with 9313 patients. The addition of ICS to LABA plus LAMA significantly reduced exacerbations (number needed to treat = 16 for 1 fewer exacerbation), but had no real effect on symptom scores or health-related quality of life. Three of these studies found that pneumonia occurred more frequently in patients treated with the additional ICS (number needed to treat to harm = 67). The authors found 3 studies with 3538 patients that evaluated the withdrawal of ICS in patients using triple therapy who have been stable for 1 year. Overall, they found no difference in the rates of subsequent pneumonia, hospitalizations, exacerbations, or all-cause mortality. The panel identified 8 randomized controlled trials with 9123 patients that evaluated the addition of ICS in patients with eosinophilia. These studies, all post hoc analyses, suggest improvements in exacerbations, dyspnea scores, and health-related quality of life at the risk of increased rates of pneumonia. The panel found 11 studies of oral corticosteroids in patients with severe and frequent exacerbations, however only 4 were randomized controlled trials (477 patients). Overall, these studies identified no differences in mortality, exacerbations, hospitalizations, or dyspnea scores but a significant increase in the risk of adverse events. Finally, the panel identified 14 randomized controlled trials (366 patients) of the use of opioids in patients with severe refractory dyspnea. Although the studies were too small to have any robust estimates on specific event rates, the patients taking opioids had improved health-related quality of life and dyspnea scores.