Orta KOAH'da inhaler kortikosteroid/ beta-2 agonist tedavisi

Global Initiative for Chronic Obstructive Lung Disease (GOLD) rehberine göre postbronkodilatör FEV1 değerinin %80-50 arasında olduğu kronik obstrüktif akciğer hastalığı (KOAH) olguları orta KOAH olarak adlandırılır. Rehberler KOAH tedavisi beklentilerini; yaşam kalitesinin, fonksiyonlarının iyileştirilmesi, fonksiyonel progresyonun yavaşlatılması, atakların ve komplikasyonların azaltılması, tedavi edilmesi, mortalitenin azaltılması olarak sıralar. Rehberler ve özellikle yaygın olarak kullanılan GOLD rehberi semptomatik orta KOAH olgularına düzenli olarak uzun etkili bronkodilatörleri tek başına ya da kombine olarak önermektedir. Bronkodilatörlerin inhalasyon yoluyla verilmesi tercih edilmektedir. Semptomatik orta KOAH olgularına salmeterol verilmesi FEV1i artırmış ve yıllık fonksiyonel progresyonu yavaşlatmıştır. Çalışmanın başında ilaç kullanmayan orta KOAH olgularına tek başına başlanan tiotropium yaşam kalitesini iyileştirmiş, FEV1i artırmış, toplam atakları etkilememiş ancak hastaneye yatmayı gerektiren atakları azaltmıştır; ancak tedavi süresinde tiotropium ile tedaviyi sürdüren hastaların %23üne ICS + LABA, %24üne ICS, %28ine LABA başlanmıştır. Tiotropium kullanmakta olan hastaların ancak %37si başkaca bir ilaç kullanmamıştır. Kullanılmakta olan herhangi bir tedaviye eklenen tiotropium da orta KOAH olgularında yaşam kalitesini iyileştirmiş, FEV1i artırmıştır. Bronkodilatörler orta KOAH olgularında rehberlerin belirttiği tedavi beklentilerinin tümünü karşılamamıştır. Fiks kombinasyon şeklinde kullanılan inhaler kortikosteroid/uzun etkili beta-2 agonist tedavisi orta KOAH olgularında FEV1de artış, yıllık fonksiyonel progresyonda yavaşlama, toplam ataklarda azalma ve mortalitede azalma meydana getirdi. Birbirlerinin etkilerini güçlendiren, KOAH tedavi beklentilerini hemen hemen karşılayan ICS/LABA kombinasyonu ile bronkodilatör ve antiinflamatuvar tedavinin birlikte yapılması KOAH tedavisi için akılcı bir çözümdür.

Inhaled corticosteroid/beta-2 agonist therapy in moderate COPD

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline defines moderate chronic obstructive pulmonary disease (COPD) as cases with postbronchodilator FEV1 values between 80-50%. Guidelines list their expectations of COPD treatment as improvement in quality of life and functions, slowing functional progresion,decreasing and treatment of exacerbations and complications and reduction in mortality. Guidelines, specifically the more commonly used GOLD guideline, recommends regular use of long acting bronchodilators alone or in combinations in symptomatic moderate COPD patients. Inhalation route is preferred. Use of salmeterol in symptomatic moderate COPD cases has increased FEV1 and slowed down annual functional progression. Use of tiotropium as a single agent in the beginning of the study has improved quality of life, increased FEV1, showed no effect on total number of exacerbations but reduced the number of exacerbations requiring hospitalization; however among patients treated with tiotropium alone, ICS + LABA, ICS alone and LABA alone had to be added to the treatment in 23%, 24% and 28% of the patients respectively. Only 37% of the patients did not need any additional treatment. Addition of tiotropium to a previous treatment has also improved quality of life and FEV1 values. Bronchodilators have failed to meet the treatment expectations defined in guidelines in moderate COPD patients. Fixed combinations of inhaler corticosteroids and long acting beta agonists caused an improvement of -3.7 units in quality of life which is statistically insignificant but clinically very close to significance. Fixed combinations also managed to increase FEV1, to slow down annual functional progression and to reduce total number of exacerbations and mortality which were all clinically and statistically significant. Use of ICS/LABA combinations, in which the components potentialize each other and which meet all of the expectations defined for COPD treatment, in bronchodilator and anti-inflammatory treatment promises to be a wise choice.

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