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Open Access
Perspectives

Inhaled corticosteroids in COPD: when are they needed, when not needed and when harmful?

PETER A. FRITH, IAN A. YANG, Kerry Hancock

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© ROBERT KNESCHKE/STOCK.ADOBE.COM MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY
© ROBERT KNESCHKE/STOCK.ADOBE.COM MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY

Abstract

Inhaled corticosteroids (ICS) have revolutionised asthma control but have a lesser role in patients with chronic obstructive pulmonary disease (COPD) and no asthma. ICS increase risk of pneumonia and other risks in patients with COPD, and long-acting bronchodilators are just as effective in many. Nevertheless, some subgroups may benefit from ICS.

Key Points

  • Inhaled corticosteroids (ICS) have revolutionised asthma control, but their use in patients with chronic obstructive pulmonary disease (COPD) is not as definitive.
  • Long-acting bronchodilators help control symptoms and reduce the risk of exacerbations for most patients with COPD.
  • Adding ICS to dual long-acting bronchodilators reduces exacerbations in patients with a history of recurrent exacerbations or coexisting asthma, especially if blood eosinophil counts are high (more than 0.35 x 109 cells/L).
  • However, use of ICS by patients with COPD increases the risk of pneumonia and some metabolic consequences.
  • ICS should not be used in patients with mild-to-moderate COPD; if already prescribed in these patients they can be judiciously withdrawn.

Chronic obstructive pulmonary disease (COPD) is a common and disabling chronic condition, affecting about 10% of the Australian population aged over 40 years, and the third highest cause of disablement from noncommunicable diseases worldwide.1 Although the most common cause of COPD in Australia is cigarette smoking, from a global perspective household air pollution and atmospheric pollution account for at least as much disease as smoking.1-3 Asthma, bronchiectasis and tuberculosis are other important causes (Figure 1).3 

In the past, COPD was considered essentially untreatable. However, the development of new therapies and guidelines on their use now allows us to treat patients with COPD. Our understanding of how to use modern medications has been so refined that we can begin to apply treatments according to the clinical characteristics or phenotype of the individual patient with COPD – so called personalised care or ‘treating traits’. This article discusses an aspect of this approach, focusing on the use of inhaled corticosteroids (ICS) to treat patients with COPD. 

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Challenges of treating COPD 

Depending in part on the aetiology of COPD, its main characteristics range between airway remodelling with fixed airflow limitation, dropout of functioning airways, partially reversible mainly small airways obstruction, luminal airway blockage by secretions and emphysema.3 The defining characteristic is airflow limitation, so the definition requires demonstration of airflow limitation with spirometry. The globally standardised criterion is a ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) below 0.7. Usually, this is accompanied by a reduced FEV1 (80% of the predicted normal value).2,3 The clinical manifestations of COPD cover a wide range, often referred to as phenotypes or treatable traits (Figure 2).4 Many studies have tried to identify meaningful endotypes of COPD (characterised by specific cells or molecules in blood or sputum), and recent research suggests the excess or paucity of eosinophils in blood may prove clinically useful. 

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All these features add to the complexity of COPD, a condition that until recently was considered inexorably progressive, ultimately fatal and essentially untreatable. Small wonder that little interest was taken in COPD in the past, and efforts to improve diagnosis and develop new treatments were often wasted.

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Changed understanding of COPD management 

Since the late 20th century there have been progressive reductions in smoking rates and the development of new drugs to treat COPD, with improved efficacy and tolerability and more effective delivery systems. Trials evaluating how the pharmacological and nondrug treatments that are now available work best in combinations, and the emergence of powerful statistical analyses such as systematic reviews and meta-analyses have all contributed to the development of guiding documents on COPD. These include expert consensus statements, evidence-based recommendations, guidelines and toolkits. We have substantially changed our understanding of and empathy with patients with COPD and our interest in helping them manage their disease.

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© ROBERT KNESCHKE/STOCK.ADOBE.COM MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY
© ROBERT KNESCHKE/STOCK.ADOBE.COM MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY
Professor Frith is Professor in Respiratory Medicine at the College of Medicine and Public Health, Flinders University, Adelaide; and Adjunct Professor in Health Sciences at the Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, SA. Professor Yang is Head of the Northside Clinical School, The University of Queensland; and Thoracic Program Medical Director at The Prince Charles Hospital, Brisbane, Qld. Dr Hancock is a GP Principal at Chandlers Hill Surgery, Adelaide, SA; an Executive Member of the COPD Coordinating Committee of Lung Foundation Australia (LFA); Chair of the GP Advisory Committee, LFA; and Chair of the Respiratory Medicine Network, Specific Interests Faculty, RACGP.