Publication date: Available online 12 May 2017
Source:Revue des Maladies Respiratoires
Author(s): G. Jebrak, I. Honore, P. Serrier, J. Dumoulin, P. Terrioux, F. Soyez, C. Maurer, G. Mangiapan, M. Febvre, L.-J. Couderc, J.-M. Braun, T. Chinet
La bronchopneumopathie chronique obstructive (BPCO) est caractérisée par une réponse inflammatoire bronchique anormale suite à l'inhalation de toxiques. Outre l'éviction de ces toxiques inhalés, il est logique de proposer un traitement anti-inflammatoire, actuellement représenté en France uniquement par les corticoïdes. Les risques de leur utilisation prolongée par voie orale sont bien connus. La voie inhalée est donc privilégiée, mais expose aussi à des effets secondaires. Dans la BPCO, il existe une sur-prescription de corticostéroïdes inhalés, notamment hors recommandation. La problématique de leur sevrage est posée. Cette revue de la littérature sur le sevrage en corticostéroïdes inhalés au cours de la BPCO a retrouvé sept études portant sur des populations hétérogènes avec des traitements associés différents. Chez les patients traités par corticostéroïdes inhalés hors recommandations, ayant peu ou pas d'exacerbation, leur arrêt paraît sans risque, sous couvert d'un traitement bronchodilatateur bien conduit. En cas de BPCO sévère avec exacerbations fréquentes, le risque d'acutisation est faible sous couvert d'un traitement bronchodilatateur optimal, mais il existe d'autres risques (déclin de la fonction respiratoire et de la qualité de vie) et une discussion au cas par cas est nécessaire, surtout s'il existe un doute avec un asthme intriqué.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.
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