The Use of Inhaled Corticosteroids to Prevent Acute Exacerbations of COPD: A Pro/Con Debate

Abstract

The use of inhaled corticosteroids (ICS) has been accepted as standard practice following early landmark studies. These demonstrated a reduction in the risk of acute exacerbations of COPD (AECOPD). However, these studies were performed at a time when other therapies were not available and now our standards of care have changed. Other data has emerged which have also raised concerns as to an increase in the incidence of pneumonia in COPD patients taking inhaled corticosteroids. It is thus timely to evaluate the evidence. We present the two sides of this debate and consider the evidence both for the use of ICS as the best therapy to reduce the risk of AECOPD and also the evidence for the use of bronchodilators as a more effective and safer alternative. It is clear that as we approach an age of personalised medicine taking a "one size fits all" approach is both intellectually and medically wrong. We present the evidence that will help clinicians make better decisions for each of their patients.

Figure 1

Proposed management of COPD incorporating two major treatable traits: symptoms due to airflow limitation and risk assessed using the blood eosinophil count. Risk refers to future risk of exacerbation and decline in FEV1. Treatments with a trait specific effect are included. Rescue short acting bronchodilators (SABA or SAMA) could be used in all situations and patient categories, as required

Figure 1

The pathological changes which lead to the symptoms of an acute exacerbation of COPD as described by Anthonisen et al. (6), adapted by author

Figure 2. a–c

Possible effect of broncho-dilators (LABA/LAMA) to reduce the rate of exacerbations by changing the threshold for symptoms to develop and detect an AECOPD. (a) Broncho-dilators reduce symptoms at all times and thus reduce the level of symptoms which develop at an exacerbation, making it milder. (b) As an exacerbation develops the broncho-dilators may reduce the level of symptoms to that below the exacerbation threshold. (c) Broncho-dilators may reduce the overall symptom burden of the patient to such a degree at both baseline and exacerbation, so the exacerbation does not reach the threshold required for detection