How can we predict which patients should take an ICS?
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.
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hoarse voice) and if the patient characteristics do not meet ICS indications then the ICS can now be confidently withdrawn, based on a number of trials.30-33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.
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