Fractional flow reserve-guided PCI.

n engl j med 372;1 nejm.org january 1, 2015 94 difference. The observed loss of FEV1 was neither a time-dependent nor a dose-dependent effect in the withdrawal group, as compared with the maintenance group. A difference of 38 ml between groups became apparent only after the final step of inhaled glucocorticoid withdrawal and did not change to a meaningful extent thereafter. Singanayagam et al. point out that we included only patients receiving maintenance therapy with inhaled glucocorticoids who had a history of exacerbation in the previous year. This reflects current treatment recommendations. In the recent Indacaterol: Switching Nonexacerbating Patients with Moderate COPD from Salmeterol/ Fluticasone to Indacaterol (INSTEAD) trial involving patients with moderate COPD who had no exacerbations during the previous year, switching patients from a combination of a long-acting β-agonist (LABA) and an inhaled glucocorticoid to an ultra-long-acting LABA did not increase the exacerbation rate during 26 weeks of treatment.1 We agree that clinicians prescribe inhaled glucocorticoids because they see value in their use, but there may be reasons other than the prevention of exacerbations for this practice, such as the convenience of combination inhalers.2 Brightling et al. suggest that we stratify our results according to the baseline blood eosinophil count. A major objective of the WISDOM trial was to identify a subgroup of patients who have a response to inhaled glucocorticoids,3 but so far we have not been able to identify a responsive phenotype on the basis of data from our prespecified subgroups.