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Perspectives

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

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

How can we predict which patients should take an ICS? 

A recent study using advanced statistical modelling suggested calculating a risk score for COPD exacerbations using:26
•   historical exacerbation rates
•   number of pack-years of smoking 
•   peripheral blood eosinophil counts. 

However, prospective trials are still needed to determine the usefulness of this score in guiding ICS use. 

Meanwhile, as a personal perspective, we suggest two new algorithms to guide initial treatment choices and follow-up treatments, respectively (Flowchart 1 and Flowchart 2). These are based on trials and meta-analyses that address individual and comparative efficacy and effectiveness of ICS, as well as their safety, together with trials reporting beneficial and potentially harmful effects of corticosteroid withdrawal or replacement. These algorithms are suggestions only, as the area remains controversial, especially in relation to the role of blood eosinophil levels in driving treatment decisions. 

Other algorithms, with varying grades of complexity, have been presented in peer-reviewed and evidence-based publications from national and international organisations, but only the COPD-X is applicable to Australian PBS prescribing.3,27,28 Evidence is mounting that lower doses of ICS may be preferable.

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What should I do if my patient is taking an ICS that I think is not necessary or advisable?

It is common to find patients with COPD who have been prescribed ICS when in fact they do not need them. Overuse of ICS has been documented in most countries, and ICS have often been prescribed as initial treatment.29 The COPD-X plan recommends that GPs and specialists review patients with COPD regularly, according to the severity of their disease symptoms or when they have had an exacerbation. If a patient has evidence of adverse corticosteroid effects (e.g. recent pneumonia, osteoporotic fractures, poorly controlled diabetes, troublesome oral candidiasis, hoarse voice) and if the patient characteristics do not meet ICS indications then the ICS can now be confidently withdrawn, based on a number of trials.30-33 

Conclusion

COPD is a complex chronic disease, with many multimorbidities and a complicated clinical trajectory. Fortunately, management options are continually evolving, with both nonpharmacological and pharmacological therapies now available to further help our patients. Some take-home messages about ICS use in patients with COPD are listed in the Box

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In summary, regarding use of ICS in patients with COPD:

  • When are ICS needed? In patients with COPD who have coexisting asthma or severe airflow obstruction (FEV1 less than 50% predicted) with frequent exacerbations, consider treatment with ICS in the form of an ICS-LABA combination plus a LAMA or a ICS-LABA-LAMA combination.
  • When are ICS not needed? Patients with mild-to-moderate COPD do not require ICS. Instead, use long-acting bronchodilators (a LAMA, a LABA or a LAMA-LABA combination).
  • When are ICS harmful? In patients with adverse effects, such as pneumonia or metabolic or other effects, consider withdrawing ICS.     RMT

 

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COMPETING INTERESTS: Professor Frith has received honoraria for advising on treatment of COPD, particularly the role of ICS, for AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Menarini, Mundipharma and Novartis; and has received expenses and speaker fees for lectures about ICS use in COPD from Asthma Australia, Lung Foundation Australia, Boehringer Ingelheim, Menarini, Monash Medical Centre, Optimum Patient Care and Novartis.  Professor Yang: None. Dr Hancock has received honoraria or speaker’s fees and expenses from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, Teva, Lung Foundation Australia, International Primary Care Respiratory Society and Optimum Patient Care (Australia).   

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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.