[The effects of inhaled steroids withdrawal in COPD]. / Impact du sevrage des corticostéroïdes inhalés dans la BPCO.

The key pathophysiological feature of chronic obstructive pulmonary disease (COPD) is an abnormal inflammatory bronchial reaction after inhalation of toxic substances. The priority is the avoidance of such toxic inhalations, but the use of anti-inflammatory drugs also seems appropriate, especially corticosteroids that are the sole anti-inflammatory drug available for this purpose in France. The risks associated with the prolonged use of these parenteral drugs are well known. Inhalation is therefore the optimal route, but inhaled drugs may also lead to adverse consequences. In COPD, there is an inhaled corticosteroids overuse, and a non-satisfactory respect of the guidelines. Consequently, their withdrawal should be considered. We reviewed seven clinical studies dealing with inhaled corticosteroids withdrawal in patients with COPD and found that included populations were heterogenous with different concomitant treatments. In non-frequent exacerbators receiving inhaled corticosteroids outside the recommendations, withdrawal appears to be safe under a well-managed bronchodilator treatment. In patients with severe COPD and frequent exacerbations, the risk of acute respiratory event is low when they receive concomitant optimal inhaled bronchodilators. However, other risks may be observed (declining lung function, quality of life) and a discussion of each case should be performed, especially in case of COPD and asthma overlap.

[The place of inhaled corticosteroids in COPD]. / Place des corticostéroïdes inhalés dans la BPCO.

INTRODUCTION: Clinical trials have provided some evidence of a favorable effect of inhaled corticosteroids on the frequency of exacerbations and on the quality of life of patients with chronic obstructive pulmonary disease (COPD). In contrast, ICS have little or no impact on lung function decline and on mortality. STATE OF THE ART: Inhaled corticosteroids are recommended only in a minority of COPD patients, those with severe disease and repeated exacerbations and probably those with the COPD and asthma overlap syndrome. However, surveys indicate that these drugs are inappropriately prescribed in a large population of patients with COPD. Overtreatment with inhaled corticosteroids exposes these patients to an increased risk of potentially severe side-effects such as pneumonia, osteoporosis, and oropharyngeal candidiasis. Moreover, it represents a major waste of health-care spending. CONCLUSION: Primary care physicians as well as pulmonologists should be better aware of the benefits as well as the side-effects and costs of inhaled corticosteroids.

[COPD and quality of life: impact of the disease in primary care in France]. / BPCO et qualité de vie : impact de la maladie en médecine générale en France.

In Europe, there are few data on the impact of chronic obstructive pulmonary disease (COPD) on patients' quality of life. This study, within primary care, addressed health-related quality of life in patients according to stage of COPD severity. The objective was to estimate the impact of the COPD on the quality of life of the patients in seven European countries (France, Belgium, Germany, Italy, the Netherlands, Spain and the United Kingdom) in 2430 patients among whom 573 patients were in France. This cross-sectional, epidemiological and non-randomized study was realized by using two generic quality of life questionnaires and two disease-specific ones. The results in the French subgroup showed an impact on patients' health occurring even in the mild stage of the disease. The differences between the severity stages, as appreciated by the general practitioners, are clinically significant with a strong dispersal of the scores of quality of life within every stage. The impact of COPD on patients' daily activities is a key feature of the disease and it is essential that this is evaluated systematically and recognized as a target for management as much as other manifestations of the disease.

Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations.

This review is the synthesis of a working group on mild asthma. Mild asthma includes intermittent and persistent mild asthma according to the Global Initiative for Asthma (GINA) classification, and affects between 50% and 75% of asthmatic patients. Mild asthma is more frequent, more symptomatic, and less well controlled in children than in adults. Cohort studies from childhood to adulthood show that asthma severity usually remains stable over time. Nevertheless, mild asthma can lead to severe exacerbations, with a frequency ranging from 0.12 to 0.77 per patient-year. Severe exacerbations in mild asthma represent 30-40% of asthma exacerbations requiring emergency consultation. In mild asthma, inflammation and structural remodelling are constant, of varying intensity, but nonspecific. Therapy with inhaled corticosteroids (ICS) decreases bronchial inflammation, but has only a slight effect on structural remodelling, and, when stopped, inflammation immediately recurs. Permanent low-dose ICS therapy is the reference treatment for persistent mild asthma. Effectiveness is to be reassessed at 3 months, and if it is insufficient the patient is no longer considered mildly asthmatic, and treatment has to be stepped up. As mild asthma is the most frequent form of the disease, diagnosis and management require physicians' particular attention.

[Characteristics of mild asthma: descriptive epidemiology and nature of bronchial inflammation. Position of the Mild Asthma Working Group]. / Caractéristiques de l'asthme léger: épidémiologie descriptive et nature de l'inflammation bronchique.

INTRODUCTION: Update on the state of knowledge in the mild asthma (intermittent and persistent mild asthma, according to the GINA classification) literature, and position of a French Mild Asthma Working Group. STATE OF THE ART: The French Mild Asthma Working Group (11 lung specialists, 4 paediatricians, 1 pharmacologist, and 1 general practitioner) selected, analysed, and summarised the literature on the epidemiology, physiopathology, clinical signs, and management of mild asthma. The present article shows the position of the working group on mild asthma descriptive epidemiology (causal factors excluded) and the nature of the bronchial inflammation. Clinical signs and medicinal treatments will be presented in a second article. PERSPECTIVES: Between 50% and 75% of asthma patients, depending on the study, present mild asthma. Childhood-to-adulthood cohort monitoring found severity to be unchanged over developmental time. Its generally benign evolution may in some (<10%) cases be complicated by severe episodes. Inflammation and airway-wall remodelling were always found, although of variable intensity, and non-specific (except for absence of infiltration by polymorphonuclear neutrophils). Corticosteroid therapy by inhalation reduces bronchial inflammation, but with little impact on airway-wall remodelling. CONCLUSION: The present findings should help clinicians in identifying and understanding mild asthma.

[Characteristics of mild asthma: clinical signs and medication use. Position statement of the Mild Asthma Working Group (174)]. / Caractéristiques de l'asthme léger: signes cliniques et traitements médicamenteux. Le point de vue du Groupe de Travail sur l'Asthme Léger.

OBJECTIVE: To update on the state of knowledge in mild asthma (intermittent and persistent mild asthma, according to the GINA classification) review the literature, and the position statement of the French Mild Asthma Working Group. METHODS: The French Mild Asthma Working Group (11 lung specialists, 4 paediatricians, 1 pharmacologist, and 1 general practitioner) selected, analysed, and summarised the literature on the descriptive epidemiology, physiopathology, clinical signs, and management of mild asthma. The position of the working group on the descriptive epidemiology (causal factors excluded) and the nature of the bronchial inflammation has been presented in a previous article. The present article focuses on the clinical features of mild asthma and the use of medication for it. RESULTS: Mild asthma was more frequent, more symptomatic, and less well controlled in children than in adults. Its generally benign evolution may in some (<10%) cases be complicated by severe episodes. Patients with mild persistent asthma require controller medication every day: permanent low-dose inhaled corticosteroid monotherapy is the reference foundation treatment for persistent mild asthma. CONCLUSIONS: The present findings should help clinicians and guide them in their approach to managing this condition.

[General practice patients at risk of chronic obstructive pulmonary disease: epidemiologic survey of 3 411 patients]. / Patients à risque de broncho-pneumopathie chronique obstructive en médecine générale. Enquête épidémiologique avec 3 411 patients.

OBJECTIVES: Describe patients at risk of chronic obstructive pulmonary disease (COPD) and analyze general practitioners' (GPs) management of COPD patients in France in 2003-2004. METHODS: EDEN, a national epidemiological survey, recruited 2 378 GPs. Each GP was to include 3 consecutive patients (aged 36-80 years) who were current or former smokers and presented respiratory symptoms (any of expectoration, cough, or dyspnea) without asthma or previously diagnosed COPD. The physician completed a standardized, anonymous questionnaire for each patient, including measurement of peak expiratory flow (PEF). RESULTS: The sample of 3 411 current smokers or former smokers with respiratory symptoms included twice as many men as women. The mean age was 58 years, with women significantly younger (p<0.0001). Men and older patients had more severe disease. Women were more often current smokers, but they smoked less than men. All patients had at least one respiratory symptom, but only 63.5% were seeing their GP for that reason. Overall, 56.5% patients reported repeated acute bronchitis, and 36.3% of these at least 3 episodes. PEF was measured in 87.7% of patients and the ratio of mean measured PEF/predicted PEF was 73.2%. GPs concluded that 92.1% of these patients had COPD, but prescribed respiratory function tests useful for only 73.8% and referred only 71.2% to a specialist. CONCLUSION: Former and current smokers underestimated their respiratory symptoms, and so did the GPs. Accordingly, COPD is diagnosed later and at a more advanced stage. Increasing GPs' awareness of COPD would improve early detection in at-risk subjects.

[Evaluation of an educational program on asthma for pharmacists]. / Evaluation d'une action de formation de pharmaciens officinaux sur l'asthme.

OBJECTIVES: The purpose of this work was to assess the impact of an educational program on asthma for dispensing pharmacists and their teams aimed at improving patient awareness and self-care (use of consultations, drug use, inhalation techniques). METHODS: This retrospective study used a before-after design (T0/T1 year). The patients were recruited by their primary care physician in the vicinity of dispensing pharmacies that had participated in the educational program. Data were collected with a self-administered questionnaire. The study population was divided into two groups, patients who were clients at a pharmacy that had participated in the program ("educated patients") or not ("non-educated patients"). RESULTS: After 1 year, there were fewer emergency consultations, more frequent follow-up visits, greater use of chronic inhalation therapy, better control of drug use techniques, and better knowledge of the asthmatic disease in "educated" patients. DISCUSSION: This study demonstrates the importance of educational programs for dispensary teams: better response to the demands of patients and physicians, better management of the disease and its treatment, better observance and consequently better control of asthma.