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So inhaled steroids slow the rate of decline of FEV1 in patients with COPD after all?
  1. P S Burge1,
  2. S A Lewis2
  1. 1Birmingham Heartlands Hospital, Birmingham, UK
  2. 2Division of Respiratory Medicine, City Hospital, University of Nottingham, Nottingham, UK
  1. Correspondence to:
    Dr Sherwood Burge, Birmingham Heartlands Hospital, Birmingham B9 5SS, UK;
    sherwood.burgeheartsol.wmids.nhs.uk

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Meta-analyses show that inhaled steroids are helpful in COPD

The medical community has made up its mind that, although inhaled corticosteroids reduce exacerbations in patients with chronic obstructive pulmonary disease (COPD),1 they do not affect disease progression.2 Despite measurement of forced expiratory volume in one second (FEV1) being widely available and a strong predictor of mortality,3 the emphasis has moved to softer outcome measures which do show changes with available treatments. Ten years ago many of us had different beliefs—several small studies using simple statistics suggested that the rate of decline in FEV1 could be reduced by about 20 ml a year by inhaled corticosteroids.4–6 This led to several large studies, the primary outcome of which was decline in FEV1 and which were powered to detect a 20 ml/year difference between active and placebo treatments.7–10 All failed to show significant differences in their primary outcome of FEV1 decline between various inhaled corticosteroids and placebo.

In this issue Sutherland and colleagues have done a meta-analysis of those trials, and have shown that inhaled corticosteroids do slow the decline in FEV1 significantly.11 How should we respond to this meta-analysis? Are the differences found clinically meaningful? Was there anything wrong with our original hypotheses or analyses? And what should we make of a similar meta-analysis that appeared to come to opposite conclusions?12

Despite the lack of clinical licences, inhaled corticosteroids have been widely prescribed for patients with COPD. In some parts of the world more that 50% of patients were receiving these drugs “off licence” by the mid 1990s.8,13 This has allowed various database studies to estimate the effect on mortality of prescribing inhaled corticosteroids.

There are problems in adequately controlling for confounders in non-randomised studies; despite …

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