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Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7245.1297 (Published 13 May 2000) Cite this as: BMJ 2000;320:1297

INHALED CORTICOSTEROIDS AND ACUTE HOSPITALISATIONS WITH COPD IN N.E.

Editor – Chronic obstructive pulmonary disease (COPD) represents a
significant health economic burden and exacerbations of the condition
commonly lead to hospitalisation. Recent evidence(1) suggests that
systemic
corticosteroids facilitate quicker attenuation of exacerbations requiring
hospitalisation: the direct therapeutic cost of Prednisolone (30mg daily
for
2 weeks) in these circumstances is £2.00. Dr Burge et al (2) conclude
that the data from the ISOLDE Trial provides an objective rationale for
the widespread use of high dose inhaled corticosteroids in all patients
with moderate to severe COPD: one may speculate that the observed annual
reduction in exacerbation frequency accompanying their use (25%) may
impact on subsequent hospitalisations.

These issue have been partly addressed in a cost description in our health
district in N. E. England (total population ~ 350,000), an area with high
pulmonary morbidity and socio-economic deprivation, in which there is an
estimated local population of 5,000 patients with moderate to severe COPD
(data acquired through a community spirometric screening programme in
general practice).

In the twelve monthly period April 1998 – March 1999, there were 1165
admissions due to exacerbations of COPD with mean duration of hospital
stay 9.5 days. The integrated health care cost per patient exacerbation
episode was estimated at £1445, with an annual accumulative cost of £1.68
million.
The annual cost of inhaled fluticasone propionate (FP) 500ugs twice daily
delivered from a 120 metered dose unit inhaler is £473. If our entire
local population with COPD was administered inhaled FP at a dose of 500ugs
twice
daily, the incurred direct tangible therapeutic cost would approach £2.4
million annually.

Is this a justifiable prospective health or cost
economic intervention given that it remains clinically speculative as to
how many
hospitalisations directly or indirectly would be offset by this
therapeutic strategy, assuming otherwise optimal clinical care?

Competing Interests: None

1. Davies L, Angus R. M, Calverley P. M. A. Oral corticosteroids in
patients admitted to hospital with exacerbations of chronic obstructive
pulmonary disease: A prospective randomised controlled trial. Lancet
1999; 354:
456-460

2. Burge P. S, Calverley P. M A, Jones P. W, Spencer S, Anderson J.
A, Maslen T. K. on behalf of the ISOLDE study investigators. Randomised
double blind placebo controlled study of fluticasone propionate in
patients with
moderate to severe chronic obstructive pulmonary disease: The ISOLDE
trial. BMJ 2000; 320: 1297-1303 (13th May).

I.K. Taylor

Consultant Physician

Department of Respiratory Medicine,
Chest Clinic,
Sunderland Royal Hospital,
Kayll Road,
Sunderland
SR4 7TP

S. A. Haggerty

Respiratory Nurse Specialist

Department of Respiratory Medicine,
Chest Clinic,
Sunderland Royal Hospital,
Kayll Road,
Sunderland
SR4 7TP

A. D. Lawrence

Research Associate

Department of Respiratory Medicine,
Chest Clinic,
Sunderland Royal Hospital
Kayll Road,
Sunderland
SR4 7TP

N. P. Keaney

Consultant Physician

Department of Respiratory Medicine,
Chest Clinic,
Sunderland Royal Hospital
Kayll Road,
Sunderland
SR4 7TP

Competing interests: No competing interests

23 May 2000
N P Keaney