Are inhaled corticosteroids (ICS) indicated for Chronic Obstructive Pulmonary Disease (COPD) exacerbation in an inpatient setting?

From the Guidelines

Inhaled corticosteroids (ICS) are indicated in COPD exacerbations in the inpatient setting, typically as part of combination therapy, to reduce airway inflammation and prevent future exacerbations. During an acute exacerbation, patients should receive a short-acting bronchodilator (such as albuterol/salbutamol 2.5-5mg via nebulizer or 4-8 puffs via MDI every 4-6 hours), systemic corticosteroids (prednisone 40mg daily for 5 days), and antibiotics if bacterial infection is suspected 1. ICS can be initiated or continued during hospitalization, particularly as combination therapy with long-acting bronchodilators. Common ICS-containing combinations include fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), or fluticasone/vilanterol (Breo Ellipta) 1.

Some key points to consider when using ICS in COPD exacerbations include:

• ICS help reduce airway inflammation, which is heightened during exacerbations, by suppressing inflammatory cell recruitment and cytokine production in the airways 1
• ICS alone are not sufficient for acute exacerbation management and should be used alongside bronchodilators and systemic steroids
• Upon discharge, patients with frequent exacerbations, elevated eosinophil counts (≥300 cells/μL), or asthma-COPD overlap should continue ICS as part of their maintenance therapy to reduce future exacerbation risk 1
• The use of ICS in COPD exacerbations is supported by guidelines from the European Respiratory Society/American Thoracic Society 1 and the American College of Chest Physicians and Canadian Thoracic Society 1

Overall, the use of ICS in COPD exacerbations is a key component of comprehensive management, and can help improve outcomes and reduce the risk of future exacerbations.

From the FDA Drug Label

The 2 exacerbation trials with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg were identical trials designed to evaluate the effect of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and salmeterol 50 mcg, each given twice daily, on exacerbations of COPD over a 12-month period Exacerbations were defined as worsening of 2 or more major symptoms (dyspnea, sputum volume, and sputum purulence) or worsening of any 1 major symptom together with any 1 of the following minor symptoms: sore throat, colds (nasal discharge and/or nasal congestion), fever without other cause, and increased cough or wheeze for at least 2 consecutive days COPD exacerbations were considered of moderate severity if treatment with systemic corticosteroids and/or antibiotics was required and were considered severe if hospitalization was required.

Inhaled Corticosteroids (ICS) Indication for COPD Exacerbation:

• The label does mention the use of fluticasone propionate and salmeterol inhalation powder for COPD exacerbations.
• However, it does not explicitly state that inhaled corticosteroids (ICS) are indicated for COPD exacerbation in an inpatient setting.
• The trials mentioned in the label were designed to evaluate the effect of fluticasone propionate and salmeterol inhalation powder on exacerbations of COPD over a 12-month period, but they do not provide information about the inpatient setting. 2

From the Research

Inhaled Corticosteroids for COPD Exacerbation

• The use of inhaled corticosteroids (ICS) in COPD patients is a topic of ongoing debate, with some studies suggesting benefits in reducing exacerbations and improving health status 3, 4.
• ICS are often used in combination with long-acting beta2-adrenoceptor agonists for high-risk symptomatic COPD patients with a history of frequent exacerbations 3, 4.
• However, the effectiveness of ICS in COPD patients may depend on various factors, including the presence of bronchiolitis, eosinophilia, responsiveness to bronchodilators, and smoking status, as suggested by the BERN acronym 4.

Acute Exacerbations of COPD

• Systemic corticosteroids are widely recommended for the treatment of acute exacerbations of COPD (AECOPD), as they improve airflow, decrease treatment failure and relapse rates, and may improve symptoms and reduce hospital stay 5, 6, 7.
• Inhaled corticosteroids may also be used in the treatment of AECOPD, particularly in patients with a history of frequent exacerbations or those who are already on ICS therapy 3, 6.
• Other effective treatments for AECOPD include inhaled bronchodilators, antibacterials, oxygen, and non-invasive ventilation 5, 6, 7.

Inpatient Setting

• In the inpatient setting, systemic corticosteroids are often used to treat AECOPD, and may be administered orally or intravenously 5, 6.
• The use of inhaled corticosteroids in the inpatient setting may be considered for patients with a history of frequent exacerbations or those who are already on ICS therapy, although the evidence is limited 3, 4.
• The management of COPD exacerbations in the inpatient setting should be individualized, taking into account the patient's medical history, severity of exacerbation, and response to treatment 5, 6, 7.