Minimizing inhaled corticosteroids for COPD

Excerpt

Background: Therapeutics Letter 145 considers the evidence for inhaled corticosteroids (ICS) as a treatment for Chronic Obstructive Pulmonary Disease (COPD). This condition is characterized by airway inflammation and irreversible airflow obstruction that causes significant respiratory symptoms and reduced quality of life. Cigarette smoking is the main cause. Stopping smoking helps symptoms and slows disease progression and improves symptoms. Drug therapy aims to alleviate symptoms, enhance functional capacity and prevent exacerbations, but has not shown by randomized trials to reduce mortality or improve quality of life.

Findings: ICS have shown limited benefits for COPD symptoms and exacerbations but increased risks of serious harms. Guidelines recommend limiting ICS to severe COPD and only for repeated exacerbations. Studies show withdrawing ICS can be done safely for stable COPD patients with infrequent exacerbations, especially those with lower eosinophil counts. Provincial, national, and international guidelines now recommend limiting ICS prescriptions to severe COPD stages. Long-term ICS use may lead to serious side effects, including pneumonia and fractures.

Conclusions: Initial COPD therapy should focus on short-acting bronchodilators, not ICS. Adding long-acting bronchodilators is recommended before considering ICS due to limited benefits and risks of serious harms. For persistent symptoms, long-acting muscarinic agonists or long-acting beta agonists are recommended, with the addition of ICS reserved for those with repeated exacerbations. Deprescribing ICS can be considered in clinically stable patients, particularly for those with infrequent exacerbations. When applicable, tapering ICS over several months is advised for patients with elevated eosinophil counts. Overall, the risks of serious harms from ICS typically outweigh their limited benefits for COPD patients