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In each medical visit, a cross-sectional evaluation, that is to say, an immediate impression, is made of the reduction of symptoms, which may include the relief of dyspnea and an improvement in exercise tolerance or in the patient's state of health. Risk reduction, however, is a medium to long-term objective that requires longitudinal assessment. Risk reduction includes reducing exacerbations, slowing disease progression, and reducing mortality. The dichotomy between short and long-term therapeutic goals may be difficult for the clinician to manage, and treatment may need to be tailored to dynamic changes in health status presented by the patient throughout the course of the disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In some other diseases, such as asthma, the more pragmatic and flexible concept of clinical disease control prevails. In asthma, the term “control” is clearly defined as no limitation in activities of daily living, no night-time symptoms, minimal or no daytime symptoms, minimal or no need for rescue therapy, no exacerbations, and normal lung function.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This concept has made it possible to set feasible therapeutic targets, and has helped to standardize treatment and adjust pharmacological regimens dynamically, with the appropriate treatment escalation and de-escalation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the case of COPD, a similar concept of disease control would be very difficult to establish. However, a favorable clinical situation can often be achieved, depending on baseline disease severity, and stability can be maintained over time, so an adapted concept of control could also be applied here. In this setting, the clinical control of COPD has been defined as “a condition of low clinical impact maintained over a long period of time”.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> This definition involves a cross-sectional dimension, namely “clinical impact” or impact of the disease on the patient at a given time, and a longitudinal dimension, namely “stability”. Clinical impact must always be as low as possible (low impact), and may vary depending on the severity of the disease, while stability is the absence of exacerbations or clinical worsening over time. Control is a combination of stability and low clinical impact.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2014, our working group proposed certain criteria for COPD control that were subsequently evaluated in various studies.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Control was evaluated on the basis of either the combination of various clinical parameters (degree of dyspnea, rescue medication use, physical activity, color of sputum, the presence of exacerbations or perception of health) or the scores obtained using validated clinical questionnaires, such as the COPD Assessment Test (CAT)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> or the Clinical COPD questionnaire (CCQ).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In general, the patients classified as controlled showed a lower future risk of exacerbations. In the end, however, the original control criteria (OCC) proved less sensitive. Only between 4.5% and 32% of patients could be classified as controlled when the clinical approach was used, and between 21% and 37% after CAT assessment, figures that were significantly lower in severe cases.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The OCC were developed as a preliminary proposal that needed to be refined and validated to assess the relevance of the variables included in the tool, their different thresholds, the number of criteria required, and the need to adjust them according to severity. The concept of control as a predictor of risk also had to be validated. This task has recently been completed, leading to the publication of our modified control criteria (MCC).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In a cohort of 265 COPD patients followed for a year, around 60% achieved control according to the MCC, irrespective of their baseline severity, compared to only 27.5% using the OCC.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The controlled patients reported better health-related quality of life, with a substantially lower CAT score at 1<span class="elsevierStyleHsp" style=""></span>year than uncontrolled patients (5.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.6 vs 10.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.7; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), and a significantly lower future risk of complication. When the MCC was used, the hazard ratio (HR) of the first compound event (mortality, hospitalization or visit to hospital emergency department) was 2.5 times higher among uncontrolled patients (HR: 2.50; 95% CI: 1.53–4.07), whereas the risk of exacerbation and hospitalization doubled in the absence of control.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our opinion, these results are promising and point toward the emergence of a new therapeutic target for COPD: clinical control of the disease. This is a therapeutic objective that is comprehensive (it combines a number of both short and long-term targets), desirable (a controlled patient can be expected to have a lower risk of future complications), easy to evaluate in clinical practice (using standard clinical variables and/or simple questionnaires), achievable for most COPD patients, (regardless of their severity at baseline), dynamic (it can be assessed at all visits), and potentially useful for clinical decision-making. The results of the validation of the MCC must be considered preliminary, and further studies are needed to confirm the initial findings and, in particular, to assess the influence of different therapeutic alternatives. However, given the temporal dichotomy of the objectives proposed in current clinical practice guidelines, we believe that the concept of clinical control in COPD may prove to be a tool that is inclusive, dynamic and useful for decision-making in our day-to-day practice.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0025" class="elsevierStylePara elsevierViewall">Juan José Soler-Cataluña has received speaker fees from AstraZeneca, Boehringer Ingelheim, Bial, Ferrer, Laboratorio Esteve, Menarini, Mundipharma, Novartis, Rovi, and TEVA; consultancy fees from AirLiquide, AstraZeneca, Boehringer Ingelheim, Chiesi, Ferrer, GlaxoSmithKline, Laboratorios Esteve, Mundipharma, and Novartis, and research grants from GlaxoSmithKline and Boehringer Ingelheim.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Bernardino Alcázar has received speaker fees from AstraZeneca, Boehringer Ingelheim, Menarini, and Novartis, and research grants from Menarini and Novartis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Marc Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Zambon, CSL Behring, Grifols, and Novartis; consultancy fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Ferrer, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratories Esteve, Ferrer, Mereo Biopharma, Verona Pharma, TEVA, pH Pharma, Novartis, and Grifols, and research grants from GlaxoSmithKline and Grifols.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Soler-Cataluña JJ, Alcázar B, Miravitlles M. Control clínico en la EPOC: ¿un nuevo objetivo terapéutico? Arch Bronconeumol. 2020;56:68–69.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía española de la enfermedad pulmonar obstructiva crónica (GesEPOC) 2017. Tratamiento farmacológico en fase estable" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Miravitlles" 1 => "J.J. Soler-Cataluña" 2 => "M. Calle" 3 => "J. Molina" 4 => "P. Almagro" 5 => "J.A. 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Year/Month | Html | Total | |
---|---|---|---|
2024 November | 6 | 2 | 8 |
2024 October | 54 | 25 | 79 |
2024 September | 56 | 30 | 86 |
2024 August | 68 | 38 | 106 |
2024 July | 45 | 21 | 66 |
2024 June | 56 | 27 | 83 |
2024 May | 59 | 30 | 89 |
2024 April | 37 | 25 | 62 |
2024 March | 44 | 27 | 71 |
2024 February | 40 | 26 | 66 |
2024 January | 1 | 0 | 1 |
2023 November | 5 | 0 | 5 |
2023 March | 6 | 5 | 11 |
2023 February | 33 | 16 | 49 |
2023 January | 35 | 39 | 74 |
2022 December | 56 | 23 | 79 |
2022 November | 64 | 32 | 96 |
2022 October | 83 | 41 | 124 |
2022 September | 38 | 27 | 65 |
2022 August | 35 | 35 | 70 |
2022 July | 35 | 47 | 82 |
2022 June | 43 | 33 | 76 |
2022 May | 39 | 23 | 62 |
2022 April | 36 | 34 | 70 |
2022 March | 58 | 44 | 102 |
2022 February | 39 | 35 | 74 |
2021 May | 2 | 2 | 4 |
2020 June | 1 | 2 | 3 |
2020 April | 2 | 2 | 4 |
2020 March | 1 | 2 | 3 |