What is the role of steroid inhalers, such as inhaled corticosteroids (ICS), in the treatment of Chronic Obstructive Pulmonary Disease (COPD)?

Role of Inhaled Corticosteroids in COPD Treatment

For patients with moderate to severe COPD who experience repeated exacerbations despite long-acting bronchodilator therapy, inhaled corticosteroids (ICS) should be used as part of combination therapy with long-acting bronchodilators, not as monotherapy. 1

Appropriate Use of ICS in COPD

When to Use ICS

• Primary indication: History of exacerbations despite appropriate bronchodilator therapy
  • Recommended for patients with moderate, severe, and very severe COPD who have repeated exacerbations 1
  • Most beneficial when blood eosinophil count is >300 cells/μL 1, 2

Recommended Combinations

1. First-line combination: ICS + long-acting β2-agonist (LABA)

   • Reduces exacerbation risk by 25-35% compared to LABA alone 3
   • Improves health-related quality of life, reduces dyspnea, decreases rescue medication use, and improves lung function 1

2. Alternative combination: ICS + LABA + long-acting muscarinic antagonist (LAMA) (triple therapy)

   • Consider for patients with persistent symptoms or further exacerbations despite dual therapy 1

Not Recommended

• ICS monotherapy is not supported for COPD treatment 1, 2
• Oral corticosteroids for long-term maintenance due to significant adverse effects 1

Benefits of ICS in COPD

• Reduces frequency of exacerbations in appropriate patients 1, 3
• Improves quality of life measures 1
• May provide mortality benefit when used in combination with LABA 1
• Prolongs time to first exacerbation 3

Risks and Adverse Effects

• Pneumonia: Higher incidence in patients using ICS

  • Risk factors: older age (>65 years), lower BMI, greater fragility, higher ICS doses, and blood eosinophils <100 cells/μL 1, 4, 2
  • In clinical trials, pneumonia occurred in 6-7% of patients using ICS/LABA compared to 2-3% with LABA alone 4

• Other potential adverse effects:

  • Oral candidiasis and hoarseness 1, 4
  • Upper respiratory tract infections 1
  • Skin bruising in patients with better lung function 5

Patient Selection Algorithm

1. Assess COPD severity and exacerbation history:

   • Moderate to severe COPD (FEV₁ <50% predicted)
   • History of ≥2 exacerbations per year or ≥1 hospitalization for exacerbation

2. Check blood eosinophil count:

   • 300 cells/μL: Strong indication for ICS

   • 100-300 cells/μL: Consider ICS based on exacerbation history
   • <100 cells/μL: Higher pneumonia risk, weigh benefits carefully 2

3. Evaluate risk factors for pneumonia:

   • Age >65 years
   • Low BMI
   • Severe COPD
   • History of pneumonia

4. Consider comorbidities:

   • History of asthma or asthma-COPD overlap: Favors ICS use 6, 2

Practical Recommendations

• Instruct patients to rinse mouth after ICS use to reduce risk of oral candidiasis 4
• Monitor for pneumonia symptoms, especially in high-risk patients
• Reassess need for continued ICS therapy periodically
• Consider ICS withdrawal in patients who have not had exacerbations for 1 year and have low eosinophil counts 1

Common Pitfalls to Avoid

1. Using ICS as monotherapy in COPD (not supported by evidence) 1, 2
2. Prescribing ICS for all COPD patients regardless of phenotype or exacerbation history
3. Failing to monitor for pneumonia in patients on ICS therapy
4. Not considering blood eosinophil levels when deciding on ICS therapy
5. Continuing ICS despite lack of benefit or presence of adverse effects

Remember that while ICS can significantly reduce exacerbations and improve quality of life in appropriate patients, they must be used selectively based on individual risk factors, exacerbation history, and inflammatory profile to maximize benefits while minimizing risks.