What inhaled corticosteroids (ICS) and medications should be given to a patient with Chronic Obstructive Pulmonary Disease (COPD) in a hospital setting?

Inhaled Corticosteroids for Hospitalized COPD Patients

For hospitalized COPD patients, triple therapy with a LAMA/LABA/ICS combination is recommended, preferably administered through a single inhaler device. 1, 2

Treatment Algorithm for Hospitalized COPD Patients

First-Line Therapy

• Triple therapy (LAMA/LABA/ICS) is the cornerstone of treatment for moderate to severe COPD patients in the hospital setting, particularly those with:
  • History of frequent exacerbations (≥2 moderate or ≥1 severe exacerbation in the previous year)
  • Persistent symptoms despite bronchodilator therapy
  • FEV1 <50% predicted 1, 2

Specific ICS Options in Triple Therapy

• Fluticasone (with salmeterol as LABA component)
• Budesonide (with formoterol as LABA component)
• Moderate doses of ICS are typically sufficient; higher doses increase adverse effects without proportional benefit 2

Administration Considerations

• Single-inhaler triple therapy (SITT) is preferred over multiple inhalers for better adherence 1, 2
• For high doses of ICS (≥1,000 μg/day), use a large-volume spacer or dry-powder system 1

Special Considerations

Exacerbation Management

• During acute exacerbations, add systemic corticosteroids (oral or IV) for short-term use (up to 30 days) 1
• Systemic corticosteroids help prevent subsequent exacerbations within the first 30 days following an initial exacerbation 1

Patient Selection for Triple Therapy

• Most beneficial for COPD patients with:
  • Blood eosinophil counts ≥300 cells/μL
  • Features of asthma-COPD overlap syndrome
  • FEV1 <50% predicted 2, 3

Risk-Benefit Assessment

• Number needed to treat: 4 patients for 1 year to prevent one moderate-severe exacerbation
• Number needed to harm: 33 patients for 1 year to cause one pneumonia 2

Important Cautions

Avoid ICS Monotherapy

• ICS should not be used as monotherapy for COPD patients 1, 4, 5
• Always combine ICS with long-acting bronchodilators (LAMA and/or LABA) 1

Monitor for Adverse Effects

• Pneumonia risk is increased with ICS use, particularly in:
  • Older patients
  • Lower BMI
  • More fragile patients
  • Those receiving higher ICS doses
  • Patients with blood eosinophils <100 cells/μL 2, 3
• Other common adverse effects include oropharyngeal candidiasis and hoarseness 4, 5

Add-on Therapies for Refractory Cases

• For patients who continue to exacerbate despite triple therapy:
  • Consider adding a macrolide (e.g., azithromycin) in former smokers with normal QT interval 2
  • Alternative: Consider roflumilast for patients with chronic bronchitis phenotype 2
  • Low-dose theophylline may enhance ICS effectiveness by increasing histone deacetylase activity 6

By following this evidence-based approach, hospitalized COPD patients can receive optimal inhaled corticosteroid therapy as part of their comprehensive treatment plan, potentially reducing exacerbation frequency, improving symptoms, and enhancing quality of life.