Comparing the effectiveness of small-particle versus large-particle inhaled corticosteroid in COPD.
OBJECTIVE
Small airway changes and dysfunction contribute importantly to airway obstruction in chronic obstructive pulmonary disease (COPD), which is currently treated with inhaled corticosteroids (ICS) and long-acting bronchodilators at Global initiative for Obstructive Lung Disease (GOLD) grades 2-4. This retrospective matched cohort analysis compared effectiveness of a representative small-particle ICS (extrafine beclomethasone) and larger-particle ICS (fluticasone) in primary care patients with COPD.


METHODS
Smokers and ex-smokers with COPD ≥ 40 years old initiating or stepping-up their dose of extrafine beclomethasone or fluticasone were matched 1:1 for demographic characteristics, index prescription year, concomitant therapies, and disease severity during 1 baseline year. During 2 subsequent years, we evaluated treatment change and COPD exacerbations, defined as emergency care/hospitalization for COPD, acute oral corticosteroids, or antibiotics for lower respiratory tract infection.


RESULTS
Mean patient age was 67 years, 57%-60% being male. For both initiation (n=334:334) and step-up (n=189:189) patients, exacerbation rates were comparable between extrafine beclomethasone and fluticasone cohorts during the 2 year outcome period. Odds of treatment stability (no exacerbation or treatment change) were significantly greater for patients initiating extrafine beclomethasone compared with fluticasone (adjusted odds ratio 2.50; 95% confidence interval, 1.32-4.73). Median ICS dose exposure during 2 outcome years was significantly lower (P<0.001) for extrafine beclomethasone than fluticasone cohorts (315 μg/day versus 436 μg/day for initiation, 438 μg/day versus 534 μg/day for step-up patients).


CONCLUSIONS
We observed that small-particle ICS at significantly lower doses had comparable effects on exacerbation rates as larger-particle ICS at higher doses, whereas initiation of small-particle ICS was associated with better odds of treatment stability during 2-years' follow-up.
University of Groningen, Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, Groningen, the Netherlands.
Dirkje S
DS
Postma
Respiratory and Intensive Care Medicine, Cochin Hospital Group, APHP, Paris-Descartes University (EA2511), Paris, France.
Nicolas
N
Roche
Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center and George Washington University School of Medicine, Washington DC, USA.
Gene
G
Colice
Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Elliot
E
Israel
Department of Medicine, National Jewish Health, Denver, CO, USA.
Richard J
RJ
Martin
Dept of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, the Netherlands.
Willem Mc
WM
van Aalderen
Blizard Institute, Queen Mary University London, London, UK.
Jonathan
J
Grigg
Research in Real Life, Ltd, Cambridge, UK.
Anne
A
Burden
Research in Real Life, Ltd, Cambridge, UK.
Elizabeth V
EV
Hillyer
Research in Real Life, Ltd, Cambridge, UK.
Julie
J
von Ziegenweidt
Respiratory, Global Scientific Affairs, Teva Pharmaceuticals, Frazer, PA, USA.
Gokul
G
Gopalan
Research in Real Life, Ltd, Cambridge, UK ; Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
David
D
Price
D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000009:adverse effects / Q000737:chemistry; D000368:Aged; D000730:Androstadienes / Q000008:administration & dosage* / Q000009:adverse effects / Q000737:chemistry; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001507:Beclomethasone / Q000008:administration & dosage* / Q000009:adverse effects / Q000737:chemistry; D018450:Disease Progression; D004636:Emergency Service, Hospital; D005260:Female; D000068298:Fluticasone; D006760:Hospitalization; D006801:Humans; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D010316:Particle Size; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012907:Smoking / Q000009:adverse effects; D016540:Smoking Cessation; D000074606:Smoking Prevention; D013997:Time Factors; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones; D000730:Androstadienes; D000900:Anti-Bacterial Agents; D000068298:Fluticasone; D001507:Beclomethasone
COPD exacerbation; extrafine particle; matched cohort analysis; real life; small airways