Pharmacologic Management of Chronic Obstructive Pulmonary Disease An Official American Thoracic Society Clinical Practice Guideline
Pharmacologic Management of Chronic Obstructive Pulmonary Disease An Official American Thoracic Society Clinical Practice Guideline
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DOI：
10.1164/rccm.202003-0625st
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发表时间：
2020-05-01
影响因子：
24.7
通讯作者：
Aaron, Shawn D.
中科院分区：
文献类型：
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作者：
Nici, Linda;Mammen, Manoj J.;Aaron, Shawn D.
背景：本文件提供了慢性阻塞性肺疾病（COPD）药物治疗的临床建议。它代表了一个小组的专家COPD临床医生和研究人员沿着与一个团队的方法学家的指导下，美国胸科Society.Methods：全面的证据综合所有相关的研究，解决了临床问题和关键的以患者为中心的专家小组商定的结果。对证据进行评估、评级和分级，并使用建议分级、评估、发展和评价方法制定建议。结果：在权衡证据质量并平衡理想和不良影响后，指南小组提出了以下建议：1）强烈建议使用长效β（2）-激动剂（LABA）/长效毒蕈碱拮抗剂（LAMA）在COPD和呼吸困难或运动不耐受患者中，联合治疗优于LABA或LAMA单药治疗; 2）有条件地推荐使用吸入性皮质类固醇（ICS）/LABA/LAMA三联疗法，而不是LABA/LAMA双联疗法。在过去一年中发生一次或多次急性加重的COPD伴呼吸困难或运动不耐受患者中的LAMA; 3）接受三联治疗的COPD患者有条件地建议停用ICS（ICS/LABA/LAMA），如果患者在过去一年内未发生急性加重; 4）不建议或反对ICS作为COPD和血嗜酸性粒细胞增多症患者长效支气管扩张剂的添加治疗，但过去一年中有一次或多次急性加重史需要抗生素或口服类固醇或住院治疗的患者除外，有条件地推荐ICS作为添加治疗; 5）有条件地建议不要在有严重和频繁加重病史的COPD患者中使用维持口服皮质类固醇;和6）有条件地建议对尽管接受了其他最佳治疗但仍出现晚期难治性呼吸困难的COPD患者进行基于阿片类药物的治疗。结论：工作组根据现有证据提出了关于COPD药物治疗的建议。需要对临床试验中代表性不足的人群进行额外研究，包括对80岁及以上COPD患者、患有多种慢性健康状况的患者以及COPD和哮喘合并诊断的患者进行研究。
Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society.Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting beta(2)-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to longacting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy.Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.