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Escalation and De-escalation of Therapy in COPD: Myths, Realities and Perspectives

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Abstract

Chronic obstructive pulmonary disease (COPD) guidelines and strategies suggest escalating treatment, mainly depending on the severity of airflow obstruction. However, some de-escalation of therapy in COPD would be appropriate, although we still do not know when we should switch, step-up or step-down treatments in our patients. Unfortunately, trials comparing different strategies of step-up and step-down treatment (e.g. treatment initiation with one single agent and then further step-up if symptoms are not controlled versus initial use of double or triple therapy, possibly with lower doses of the individual components, or the role of N-acetylcysteine in combination therapy for a step-down approach) are still lacking. In general, there is a large and often inappropriate use of the inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) combination. However, the withdrawal of the ICS in COPD patients at low risk of exacerbation can be safe, provided that patients are under regular treatment with long-acting bronchodilators. Maximising the treatment in patients with a degree of clinical instability by including an ICS in the therapeutic regimen is useful to control the disease, but may not be needed during periods of clinical stability. In patients with severe but stable COPD, the withdrawal of the ICS from triple therapy [LABA + long-acting muscarinic antagonist (LAMA) + ICS] is possible, but not when the patient has been hospitalised for an acute exacerbation of COPD. We must still establish how long we should wait before withdrawing the ICS. It is still unclear whether the same is true when only the LABA or the LAMA is withdrawn while continuing treatment with the other bronchodilator and the ICS. In any case, we strongly believe that it is always better to avoid a therapeutic step-up progression when it is not needed rather than being forced subsequently into a step-down approach in which the outcome is always unpredictable.

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Authors and Affiliations

  1. Chair of Respiratory Medicine, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy

    Mario Cazzola & Paola Rogliani

  2. Respiratory Pharmacology Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy

    Mario Cazzola

  3. Division of Respiratory Medicine, University Hospital Tor Vergata, Rome, Italy

    Mario Cazzola & Paola Rogliani

  4. Unit of Pharmacology, Department of Experimental Medicine, Second University of Naples, Naples, Italy

    Maria Gabriella Matera

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  1. Mario Cazzola
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Correspondence to Mario Cazzola.

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Conflict of interest

M. Cazzola is a consultant at Chiesi Farmaceutici, Zambon and Novartis, and has undertaken research funded by Novartis, AstraZeneca and Almirall. He is also a member of the Novartis, GSK, AstraZeneca, Zambon, Mundipharma and Boehringer Ingelheim speaker bureau. P. Rogliani is a member of the AstraZeneca and Boehringer Ingelheim speaker bureau. M. G. Matera has undertaken research funded by Novartis and is a member of the Boehringer Ingelheim speaker bureau.

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Cazzola, M., Rogliani, P. & Matera, M.G. Escalation and De-escalation of Therapy in COPD: Myths, Realities and Perspectives. Drugs 75, 1575–1585 (2015). https://doi.org/10.1007/s40265-015-0450-6

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