TY - JOUR T1 - Withdrawal of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease: A European Respiratory Society Guideline JF - European Respiratory Journal JO - Eur Respir J DO - 10.1183/13993003.00351-2020 SP - 2000351 AU - James D. Chalmers AU - Irena F. Laska AU - Frits M. E. Franssen AU - Wim Janssens AU - Ian Pavord AU - David Rigau AU - Melissa J. McDonnell AU - Nicolas Roche AU - Don D. Sin AU - Daiana Stolz AU - Samy Suissa AU - Jadwiga Wedzicha AU - Marc Miravitlles Y1 - 2020/01/01 UR - http://erj.ersjournals.com/content/early/2020/03/17/13993003.00351-2020.abstract N2 - Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendation formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of interventions, the guideline panel made: a) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations; b) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ⩾300 eosinophils·µL−1; c) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.Conditional recommendations indicate that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.FootnotesThis manuscript has recently been accepted for publication in the European Respiratory Journal. It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article.Conflict of interest: Dr. Chalmers reports grants and personal fees from Glaxosmithkline, grants and personal fees from Insmed, grants and personal fees from Astrazeneca, personal fees from Zambon, grants from Gilead, grants and personal fees from Boehringer ingelheim, grants from Grifols, outside the submitted work.Conflict of interest: Dr Laska has nothing to disclose.Conflict of interest: Dr. Franssen reports grants and personal fees from AstraZeneca, personal fees from Boehringer Ingelheim, personal fees from Chiesi, personal fees from GlaxoSmithKline, grants and personal fees from Novartis, personal fees from TEVA, outside the submitted work.Conflict of interest: Dr. Janssens reports to receive grants, speakers' and consultancy fees from Chiesi, AstraZeneca, Boerhinger, GSK, outside the submitted work .Conflict of interest: Dr. Pavord reports personal fees from AstraZeneca, personal fees from Boehringer Ingelheim, personal fees from Aerocrine, personal fees from Almirall, personal fees from Novartis, personal fees from GlaxoSmithKline, personal fees from Genentech, personal fees from Regeneron, from Teva, from Chiesi, from Sanofi, from Circassia, from Knopp, grants from NIHR, outside the submitted work.Conflict of interest: Dr. Rigau reports and declares he works as methodologist of the ERS.Conflict of interest: Dr. McDonnell reports personal fees from Boehringer Ingelheim, personal fees from Menarini, grants from Health Resarch Board Ireland, outside the submitted work.Conflict of interest: Dr. Roche reports grants and personal fees from Boehringer Ingelheim, grants and personal fees from Novartis, personal fees from Teva, personal fees from GSK, personal fees from AstraZeneca, personal fees from Chiesi, personal fees from Mundipharma, grants and personal fees from Pfizer, personal fees from Sanofi, personal fees from Sandoz, personal fees from 3M, personal fees from Zambon, personal fees from Trudell, outside the submitted work.Conflict of interest: Dr. Sin reports grants from Merck, personal fees from Sanofi-Aventis, personal fees from Regeneron, grants and personal fees from Boehringer Ingelheim, grants and personal fees from AstraZeneca, personal fees from Novartis, outside the submitted work.Conflict of interest: Daiana StolzConflict of interest: Dr. Suissa reports grants and personal fees from Novartis, grants and personal fees from Boehringer-Ingelheim, personal fees from AstraZeneca, outside the submitted work.Conflict of interest: Dr. Wedzicha reports grants from GSK, grants from Johnson and Johnson, other from Novartis, other from Boehringer Ingelheim, other from Astra Zeneca, other from GSK, grants from GSK, grants from Astra Zeneca, grants from Boehringer Ingelheim, grants from Novartis, outside the submitted work.Conflict of interest: Dr. Miravitlles reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Zambon, Sandoz, CSL Behring, Grifols and Novartis, personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, Kamada, TEVA, Sanofi, pH Pharma, Novartis and Grifols, grants from GlaxoSmithKline and Grifols, outside the submitted work. 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