CHEST Guidelines-Rebuttal-From-Dr-Chalmers_2018

Rebuttal-From-Dr-Chalmers_2018_chest

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Dr. James D. Chalmers and Dr. Ian D. Pavord discuss the approach to using inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD). Both agree that ICS are mainly effective for eosinophilic airway inflammation and less so for the more common neutrophilic inflammation in COPD. Dr. Chalmers suggests considering ICS withdrawal for all COPD patients, provided that their exacerbation history and blood eosinophil levels are reviewed. Withdrawal is not recommended in those with a history of exacerbations and eosinophilia. Chalmers criticizes the heavy reliance on blood eosinophil counts for clinical decisions, noting that these counts are not a perfect surrogate for identifying patients at risk of exacerbations. He emphasizes a comprehensive approach incorporating clinical data, disease severity, and patient preferences in managing ICS therapy to avoid chronic overuse that may harm patients and the healthcare system.<br /><br />Dr. Pavord echoes many of Chalmers’ views, highlighting an emerging consensus on ICS use in COPD. He supports using blood eosinophil counts as a biomarker for eosinophilic airway inflammation and prioritizing ICS use for secondary prevention in patients with a history of exacerbations. Pavord argues that treatment should be based on the biology of the disease, rather than arbitrary labels. He suggests that not all patients need triple therapy (ICS/LABA/LAMA) and that some can manage effectively with ICS/LABA. Pavord proposes a more flexible blood eosinophil cutoff of 150 cells/mm³ for deciding continuation of ICS, consistent with findings from the WISDOM trial indicating successful ICS withdrawal at this threshold. Both authors call for a shift from a one-size-fits-all to a more personalized treatment strategy for COPD.

Keywords

inhaled corticosteroids

chronic obstructive pulmonary disease

eosinophilic airway inflammation

neutrophilic inflammation

ICS withdrawal

blood eosinophil counts

exacerbations

personalized treatment

COPD management

WISDOM trial