Appropriate use of inhaled corticosteroids in COPD: the candidates for safe withdrawal

Abstract

International guidance on chronic obstructive pulmonary disease (COPD) management recommends the use of inhaled corticosteroids (ICS) in those patients at increased likelihood of exacerbation. In spite of this guidance, ICS are prescribed in a large number of patients who are unlikely to benefit. Given the evidence of the risks associated with ICS and the limited indications for their use, there is interest in understanding the effects of withdrawing ICS when prescribed inappropriately. In this review, we discuss the findings of large ICS withdrawal trials, with primary focus on the more recent trials using active comparators. Data from these trials indicate that ICS may be withdrawn without adverse impact on exacerbation risk and patient-reported outcomes in patients with moderate COPD and no history of frequent exacerbations. Considering the safety concerns associated with ICS use, these medications should be withdrawn in patients for whom they are not recommended, while maintaining adequate bronchodilator therapy.

Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease (COPD): Boon or Bane?

“…Results from several studies have shown that long-term use of ICS alone or in combination with a LABA increased the risk of pneumonia. 11,[32][33][34] For example, in a 1-year double-blind study, the risk of pneumonia was significantly higher when an ICS was used in combination with a LABA versus LABA alone. 32 Further, findings from a patientlevel meta-analysis suggested that patients with COPD and lower blood eosinophil counts (<2%) who were treated with ICS had more pneumonia events than those with higher counts.…”

“…55 Moreover, higher blood eosinophil counts are purported to predict increased exacerbation rates and greater treatment effect with LABA 1 ICS versus LABA alone in patients with COPD. 34,56,57 For example, in a post-hoc analysis of 2 clinical trials in patients with moderate-to-severe COPD and ≥1 exacerbation within a year before screening, the LABA 1 ICS combination of vilanterol 1 fluticasone furoate reduced exacerbations up to 24% in patients with blood eosinophil counts of ≥2 to <4%, 32% in those with counts of 4% to <6%, and 42% in those with counts ≥6% compared with vilanterol alone. 55 These results suggest that an increased blood eosinophil count is likely a predictive marker for response to ICS-based treatment in patients with COPD.…”

Pros and Cons of Inhaled Corticosteroids Withdrawal in Chronic Obstructive Pulmonary Disease

“…This manuscript is not aimed to discuss whether, when, why, and how ICS should or should not be prescribed in COPD [1][2][3] . Rather, our purpose is to examine the published literature to consider whether ICS can be safely discontinued in COPD patients who do not need them on the basis of the available evidence 4,5 . Interestingly, this is also on its way to become a classic debate 6,7 .…”

“…It is well documented that ICS are widely prescribed in patients with stable COPD regardless of any guidance recommendation, across all levels of airflow limitation severity and exacerbation risk [5][6][7][8][9][10][11][12] . It would be reasonable to state that ICS are overprescribed in COPD patients [8][9][10][11][12] .…”

COPD or functionally COPD?

“…The basis of this problem seems to lie in the chronic confusion between COPD and non-reversible or only partially reversible obstruction of the airways, that is, a functionally COPD. Moreover, safe withdrawal or deprescribing of ICS in patients with COPD should be done according to sound criteria [1].…”