Stepping down steroids

DOES IT STILL EXIST? The American art of Guided Chaos is NOT tai chi. But it applies internal principles for combat in a free-form, dynamic way that many high-level tai chi instructors have said is closer to true "combat tai chi" than any other martial tai chi fight training available.

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"John Perkins has mastered the real world application of Combat Tai Chi"

---Dr. Drew Miller, Coordinator of Degerberg Martial Arts Academy, Chicago Illinois, former senior student of Tai Chi Master Wayson Liao. Owner 1st Army Military Supply

Alan G Kaplan 1,2

1 Family Physician Airways Group of Canada, 2 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

Abstract: Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β 2 -agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.

Keywords: chronic obstructive pulmonary disease, inhaled corticosteroid, withdrawal, bronchodilation, clinical practice, algorithm

Stepping down steroids

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