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This work by Griffith and colleagues is an elegant approach to what is considered by many as a clumsy and maladroit dilemma in medicine, reassessing our perspectives on overdoing potentially harmful medical therapies. While the population is somewhat homogenous, predominantly male VA patients, the authors found wide variance in prescribing patterns and problems with adhering to guidelines in use of inhaled corticosteroids among patients diagnosed with COPD. Corticosteroids are often overused among primary care providers for both asthma and COPD due to lack of knowledge of potential harms and pressures from patients presenting with dyspnea to “do something” which translates to prescribing something.1 Not only can inhaled corticosteroids lead to increased rates of pneumonia; certain combinations have been associated with higher rates of sepsis, bacteremia, and skin infections among patients with COPD.2,3,4
Questions that arise from this research include the following: Can we systematically enhance primary care providers’ knowledge and experience with COPD management and align prescribing practice with more rigorous disease phenotypes while offering an algorithm of options for treatment for patients with dyspnea from other comorbidities? Can we build an educational program that is broadly generalizable to wide sectors of the population where pharmaceutical influence has traction and seeks to sell prescriptions? Can we make this approach of scientific de-escalation of therapy intriguing enough to the gatekeepers that they become invested in it with as much equity as the authors that shepherd the work?
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Stryczek K, Lea C, Gillespie C, Sayre G, Warner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing inhaled corticosteroids to improve care and safety in COPD treatment: primary care providers’ perspectives. J Gen Intern Med 2019 Aug 8.
Wang CY, Lin YS, Wang YH, Lai CC, Wang HC, Chen L, Yu CJ, Taiwan Clinical Trial Consortium for Clinical Trial Diseases (TCORE). Risk of sepsis among patients with COPD treated with fixed combinations of inhaled corticosteroids and long-acting Beta2 agonists. Aging 2019 Sep 10;11(17):6863–6871
Griffith MF, Feemster LC, Zeliadt SB, Donovan LM, Spece LJ, Udris EM, Hau DH. Overuse and misuse of inhaled corticosteroids among Veterans with COPD: a cross-sectional study evaluating targets for de-implementation. Journal Gen Intern Med. SPI 5461.
Corder MP, Veteran’s health care: time for a change? Physician Exec 1998 Nov-Dec;24(6):48–51
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Barney, J. Capsule Commentary on Griffith et al., Overuse and Misuse of Inhaled Corticosteroids Among Veterans with COPD: a Cross-Sectional Study Evaluating Targets for De-implementation. J GEN INTERN MED 35, 979 (2020). https://doi.org/10.1007/s11606-019-05598-z
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DOI: https://doi.org/10.1007/s11606-019-05598-z