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Rationale: In chronic obstructive pulmonary disease (COPD), inhaled corticosteroids (ICS) are associated with pneumonia, highlighting the importance of investigating subgroups of patients who may benefit from prolonged ICS use. Despite this, the WISDOM (Withdrawal of Inhaled Steroids during Optimized Bronchodilator Management) trial found a greater decline in forced expiratory volume in 1 second (FEV1) in patients with COPD who withdrew from ICS compared with patients who remained on triple therapy. Objectives: We investigated the association between ICS withdrawal and the rate of FEV1 decline in patients with COPD using routinely collected electronic healthcare records. Methods: Using CPRD (Clinical Practice Research Datalink) Aurum and Hospital episode statistics, we included patients with COPD who had been on triple therapy for at least 4 months. Patients were categorized into those who withdrew from ICS and those who remained on triple therapy during follow-up. Three cohorts were created: 1) patients meeting the WISDOM trial eligibility criteria; 2) patients with COPD not restricted by the WISDOM trial eligibility criteria; and 3) patients who would have been excluded from the WISDOM trial on the basis of their comorbidities. Mixed linear regression was used to model the association between ICS withdrawal and the rate of FEV1 decline (ml/year) adjusted for baseline characteristics. Results: A total of 6,008 patients with COPD met the WISDOM eligibility criteria, of which 9.0% withdrew from ICS. Mean rates of FEV1 declined -7.8 ml/year (95% confidence interval [CI], -19.7 to 4.1) for withdrawers and -15.2 ml/year (95% CI, -18.7 to -11.8) for those who remained on triple therapy (difference, P = 0.264). A total of 60,645 patients with COPD were not restricted by the WISDOM eligibility criteria. The mean rate of FEV1 decline was -32.6 ml/year (95% CI, -33.6 to -31.5) for withdrawers and -36.4 ml/year (95% CI, -39.4 to -33.4) for those who remained on triple therapy. A total of 32,882 patients with COPD were included in the last population representing those who would have been excluded from the WISDOM trial because of their comorbidities. The mean rate of FEV1 decline was -29.4 ml/year (95% CI, -30 to -28.1) in withdrawers and -31.3 ml/year (95% CI, -35 to -27.5) in those who remained on triple therapy. Conclusions: The rate of FEV1 decline was similar between patients on triple therapy and patients who withdrew from ICS regardless of the specific COPD population studied. In routine clinical practice, few patients with COPD meet WISDOM eligibility criteria, and few patients are withdrawn from ICS. [ABSTRACT FROM AUTHOR]

Accurate prognosis information after a diagnosis of chronic obstructive pulmonary disease (COPD) would facilitate earlier and better informed decisions about the use of prevention strategies and advanced care plans. We therefore aimed to develop and validate an accurate prognosis model for incident COPD cases using only information present in general practitioner (GP) records at the point of diagnosis. Incident COPD patients between 2004–2012 over the age of 35 were studied using records from 396 general practices in England. We developed a model to predict all-cause five-year mortality at the point of COPD diagnosis, using 47,964 English patients. Our model uses age, gender, smoking status, body mass index, forced expiratory volume in 1-second (FEV1) % predicted and 16 co-morbidities (the same number as the Charlson Co-morbidity Index). The performance of our chosen model was validated in all countries of the UK (N = 48,304). Our model performed well, and performed consistently in validation data. The validation area under the curves in each country varied between 0.783–0.809 and the calibration slopes between 0.911–1.04. Our model performed better in this context than models based on the Charlson Co-morbidity Index or Cambridge Multimorbidity Score. We have developed and validated a model that outperforms general multimorbidity scores at predicting five-year mortality after COPD diagnosis. Our model includes only data routinely collected before COPD diagnosis, allowing it to be readily translated into clinical practice, and has been made available through an online risk calculator (https://skiddle.shinyapps.io/incidentcopdsurvival/). [ABSTRACT FROM AUTHOR]

Background: Inhaled corticosteroid (ICS)-containing medications slow rate of decline of FEV 1 . Blood eosinophil (EOS) levels are associated with the degree of exacerbation reduction with ICS. Purpose: We investigated whether FEV 1 decline differs between patients with and without ICS, stratified by blood EOS level. Patients and methods: The UK Clinical Practice Research Datalink (primary care records) and Hospital Episode Statistics (hospital records) were used to identify COPD patients aged 35 years or older, who were current or ex-smokers with ≥2 FEV 1 measurements ≥6 months apart. Prevalent ICS use and the nearest EOS count to start of follow-up were identified. Patients were classified at baseline as higher stratum EOS (≥150 cell/µL) on ICS; higher stratum EOS not on ICS; lower stratum EOS (<150 cells/µL) on ICS; and lower stratum EOS not on ICS. In addition, an incident ICS cohort was used to investigate the rate of FEV 1 change by EOS and incident ICS use. Mixed-effects linear regression was used to compare rates of FEV 1 change in mL/year. Results: A total of 26,675 COPD patients met our inclusion criteria (median age 69, 46% female). The median duration of follow up was 4.2 years. The rate of FEV 1 change in prevalent ICS users was slower than non-ICS users (-12.6 mL/year vs -21.1 mL/year; P  =0.001). The rate of FEV 1 change was not significantly different when stratified by EOS level. The rate of FEV 1 change in incident ICS users increased (+4.2 mL/year) vs -21.2 mL/year loss in non-ICS users; P <0.001. In patients with high EOS, incident ICS patients showed an increase in FEV 1 (+12 mL/year) compared to non-ICS users whose FEV 1 decreased (-20.8 mL/year); P <0.001. No statistical difference was seen in low EOS patients. Incident ICS use is associated with an improvement in FEV 1 change, however, over time this association is lost. Conclusion: Regardless of blood EOS level, prevalent ICS use is associated with slower rates of FEV 1 decline in COPD., Competing Interests: Miss Whittaker reports grants from GlaxoSmithKline, during the conduct of the study; Dr Müllerova was employed by and reported personal fees from GlaxoSmithKline, during the conduct of the study; Dr Jarvis reports grants from European Union and Cystic Fibrosis Trust, outside the submitted work; she also reports grants from GlaxoSmithKline, during the conduct of the study. Dr Barnes is employed, holds shares and reports personal fees from GlaxoSmithKline, outside the submitted work; he also received grants from GlaxoSmithKline, during the conduct of the study. Dr Jones is employed by and reports personal fees from GlaxoSmithKline, during the conduct of the study; Dr Compton is employed, holds shares and reports personal fees from GlaxoSmithKline, during the conduct of the study; Dr Kiddle reports grants from MRC, during the conduct of the study; grants from Roche Diagnostics, Engineering and Physical Sciences Research Council, Biotechnology and Biological Sciences Research Council, National Institute for Health Research, Alzheimer’s Society, Eli Lily, and Jannsen, outside the submitted work; Dr Kiddle was supported by a MRC Career Development Award (MR/PO21573/1). Dr Quint reports grants from GlaxoSmithKline, during the conduct of the study; grants from The Health Foundation, MRC, Wellcome Trust, British Lung Foundation, Insmed, AstraZeneca, Bayer, Boehringer Ingelheim, Chiesi, Teva, and GlaxoSmithKline, outside the submitted work. The authors report no other conflicts of interest in this work.