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Review
. 2023 Jul 24;33(1):27.
doi: 10.1038/s41533-023-00347-6.

Rational use of inhaled corticosteroids for the treatment of COPD

Jennifer K Quint  1 , Amnon Ariel  2 , Peter J Barnes  3
Affiliations
Review

Rational use of inhaled corticosteroids for the treatment of COPD

Jennifer K Quint et al. NPJ Prim Care Respir Med. .

Abstract

Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.

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Conflict of interest statement

J.K.Q. declares personal fees for advisory board participation or speaking fees from GlaxoSmithKline, Boehringer Ingelheim, AstraZeneca and Chiesi, but declares no non-financial competing interests. A.A. declares personal fees from AstraZeneca, and personal fees and non-financial support from Boehringer Ingelheim, outside the submitted work. P.J.B. declares research funding from AstraZeneca and Boehringer Ingelheim; consulting fees from AstraZeneca, Boehringer Ingelheim and Teva; and payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from AstraZeneca, Boehringer Ingelheim, Novartis and Teva. P.J.B. declares no non-financial competing interests.

Figures

Fig. 1
Fig. 1. GOLD 2023.
Initial pharmacological treatment. *Single inhaler therapy may be more convenient and effective than multiple inhalers. Groups C and D from GOLD 2011–2022 have been replaced by Group E in GOLD 2023. CAT COPD Assessment Test, Eos eosinophils, GOLD Global Initiative for Chronic Obstructive Lung Disease, ICS inhaled corticosteroids, LABA long-acting β2-agonist, LAMA long-acting muscarinic antagonist, mMRC modified Medical Research Council. © 2022, 2023, Global Initiative for Chronic Obstructive Lung Disease, available from www.goldcopd.org, published in Deer Park, IL, USA.
Fig. 2
Fig. 2. Real-world studies comparing LAMA/LABA with triple therapy or LABA/ICS in patients with COPD*.
*Data from Voorham et al., Suissa et al.,,, Cabrera et al. and Ashdown et al. transformed for consistent presentation (favours non-ICS-containing therapy on left; favours ICS-containing therapy on right). †HRs are for time to first event after treatment initiation. Suissa et al., patients aged >55 years initiating LAMA/LABA or LABA/ICS; Voorham et al., patients aged >40 years with a history of smoking and no maintenance/LAMA therapy and ≥2 exacerbations in the previous year; Suissa et al., patients aged >55 years initiating LAMA/LABA/ICS or LAMA/LABA; Suissa et al., patients aged >50 years initiating LAMA/LABA/ICS or LAMA/LABA; Cabrera et al., patients initiating ICS vs. non-ICS-containing treatments; Quint et al., patients aged ≥40 years with ≥1 prescription of LAMA/LABA/ICS or LAMA/LABA; Suissa et al., patients aged ≥40 years initiating treatment with single-inhaler LAMA/LABA/ICS, or LAMA/LABA. CI confidence interval, COPD chronic obstructive pulmonary disease, HR hazard ratio, ICS inhaled corticosteroids, LABA long-acting β2-agonist, LAMA long-acting muscarinic antagonist.
Fig. 3
Fig. 3. Practical guide to prescribing ICS for the treatment of COPD.
Adapted from the International Primary Care Respiratory Group (IPCRG) desktop helper for the appropriate use and withdrawal of ICS, 2020. Available at link. *This may include asthmatic features/features suggesting steroid responsiveness, including any previous, secure diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%). †Or since previous assessment if less than 12 months. ‡For patients with exacerbations despite triple therapy (LAMA/LABA/ICS), consider add-on therapy with roflumilast or macrolides. §If blood eosinophil count is 150–300 cells/μl, reduce ICS dose/switch to an ICS with a better safety profile. If blood eosinophil count is <150 cells/µl, and there is no/questionable asthma history or exacerbation in the previous 12 months, consider withdrawal as risks of ICS are likely to outweigh any benefit. COPD chronic obstructive pulmonary disease, FEV1 forced expiratory volume in 1 s, ICS inhaled corticosteroids, LABA long-acting β2-agonist, LAMA long-acting muscarinic antagonist.
Fig. 4
Fig. 4. Summary of the European Respiratory Society guidelines on withdrawal of ICS in COPD.
COPD chronic obstructive pulmonary disease, ICS inhaled corticosteroids. Reproduced with permission of the © ERS 2022. European Respiratory Journal 55 (6) 2000351; 10.1183/13993003.00351-2020 Published 4 June 2020.
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References

    1. Global Initiative for Asthma. Global strategy for asthma management and prevention, https://ginasthma.org/wp-content/uploads/2022/05/GINA-Main-Report-2022-F... (2022).
    1. Singh D. Pharmacological treatment of stable chronic obstructive pulmonary disease. Respirology. 2021;26:643–651. doi: 10.1111/resp.14046. - DOI - PubMed
    1. Contoli M, Morandi L, Di Marco F, Carone M. A perspective for chronic obstructive pulmonary disease (COPD) management: six key clinical questions to improve disease treatment. Expert Opin. Pharmacother. 2021;22:427–437. doi: 10.1080/14656566.2020.1828352. - DOI - PubMed
    1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: 2023 report. https://goldcopd.org/wp-content/uploads/2023/03/GOLD-2023-ver-1.3-17Feb2... (2022).
    1. Lipson DA, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N. Engl. J. Med. 2018;378:1671–1680. doi: 10.1056/NEJMoa1713901. - DOI - PubMed

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