From the Guidelines
Two or more COPD exacerbations per year is the threshold for considering the addition of inhaled corticosteroids (ICS) to a treatment regimen. For patients who experience frequent exacerbations despite being on appropriate bronchodilator therapy (such as a long-acting beta-agonist [LABA] and/or a long-acting muscarinic antagonist [LAMA]), adding an ICS can help reduce the risk of future exacerbations 1. Common ICS medications used in COPD include fluticasone, budesonide, and beclomethasone, typically administered twice daily via an inhaler, often as part of a combination product with a LABA (such as fluticasone/salmeterol, budesonide/formoterol).
Key Considerations
- ICS therapy is particularly beneficial for patients who have features of asthma-COPD overlap or elevated blood eosinophil counts (typically >300 cells/μL) 1.
- However, ICS use carries risks including increased pneumonia susceptibility, so the decision should balance the potential benefits of reduced exacerbations against these risks.
- Regular follow-up is essential to assess treatment response and monitor for adverse effects, with consideration of ICS withdrawal if the patient remains stable without exacerbations for an extended period.
Guidelines and Recommendations
- The 2017 European Respiratory Society/American Thoracic Society guideline recommends considering ICS for patients with two or more exacerbations per year or one or more exacerbations requiring hospitalisation 1.
- The 2016 review of national guidelines for management of COPD in Europe also supports the use of ICS in patients with frequent exacerbations, despite variations in specific criteria across countries 1.
From the Research
COPD Exacerbations and ICS Treatment
The number of Chronic Obstructive Pulmonary Disease (COPD) exacerbations per year that necessitates the addition of Inhaled Corticosteroids (ICS) to a treatment regimen is not strictly defined but is generally considered in the context of frequent or severe exacerbations.
- Patients with a history of multiple or severe exacerbations despite appropriate maintenance bronchodilator use, particularly if blood eosinophils are >300 cells/µL-1, are likely to benefit from the addition of ICS to long-acting bronchodilators 2.
- The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document suggests that ICS should be considered for patients with COPD who have a history of exacerbations, especially if they have had two or more exacerbations in the past year or one exacerbation that required hospitalization 3, 2.
- A study analyzing the effect of adding ICS to long-acting bronchodilators for COPD found that the benefit of combination therapy was more pronounced in patients with recent out-of-hospital exacerbations, with an adjusted hazard ratio of 0.63 (95% CI: 0.44-0.90; p-value: 0.012) 4.
Considerations for ICS Addition
When considering the addition of ICS to a COPD treatment regimen, several factors should be taken into account, including:
- The frequency and severity of exacerbations 2, 4.
- Blood eosinophil levels, with higher levels potentially indicating a greater benefit from ICS addition 2.
- The presence of concomitant asthma or a history of asthma 2.
- The risk of pneumonia, which is higher in older patients, those with lower body mass index (BMI), greater overall fragility, receiving higher ICS doses, and those with blood eosinophils <100 cells/µL-1 2.
Treatment Paradigm
The role of ICS in COPD management is evolving, with a shift towards reserving ICS for patients with more severe disease who are not controlled on dual bronchodilator therapy 3, 5.
- ICS/LABA combinations have been shown to reduce moderate-to-severe exacerbations, but the efficacy in reducing severe exacerbations is modest and variable 6.
- The introduction of new classes of medications, such as long-acting muscarinic antagonists (LAMA) and ultra-LABAs, is likely to impact the treatment paradigm for COPD 3, 5.