How should a provider proceed with withdrawing inhaled corticosteroids (ICS) in a stable chronic obstructive pulmonary disease (COPD) patient, considering the WISDOM trial findings?

ICS Withdrawal in Stable COPD with Low Blood Eosinophil Count

Gradually withdraw the inhaled corticosteroid (ICS) component while monitoring the patient closely for exacerbations, as the WISDOM trial findings suggest this approach will not increase the risk of exacerbations in patients with low blood eosinophil counts (<100 cells/μL). 1

Patient Assessment and Risk Stratification

This 55-year-old male has several factors that support ICS withdrawal:

• Stable COPD for more than 1 year with no exacerbations
• Low blood eosinophil count (50 cells/μL)
• Currently on triple therapy (LAMA/LABA/ICS)

Blood Eosinophil Count as a Biomarker

The patient's blood eosinophil count of 50 cells/μL is particularly important in this decision-making process. Post-hoc analysis of the WISDOM trial demonstrated that patients with blood eosinophil counts <100 cells/μL did not experience increased exacerbation risk following ICS withdrawal 1.

Evidence-Based Withdrawal Protocol

Based on the 2023 Canadian Thoracic Society guidelines and WISDOM trial findings, here's the recommended approach:

1. Gradual withdrawal rather than abrupt discontinuation

   • Begin by reducing the fluticasone dose by 50% for 6-8 weeks
   • Then completely discontinue the ICS component while maintaining dual bronchodilator therapy

2. Maintain dual bronchodilator therapy

   • Continue tiotropium 18 mcg once daily (LAMA)
   • Continue salmeterol component 50 mcg twice daily (LABA)

3. Close monitoring during withdrawal period

   • Schedule follow-up visits at 4-6 week intervals during withdrawal
   • Monitor for symptoms, lung function changes, and exacerbations
   • Be prepared to reinstate ICS if clinical deterioration occurs

Rationale for ICS Withdrawal

Several factors support this recommendation:

1. Risk-benefit assessment: ICS therapy carries risks including pneumonia, oral candidiasis, skin bruising, and potential systemic effects 2, 3

2. WISDOM trial findings: This landmark study demonstrated that in patients with severe COPD, gradual withdrawal of ICS did not increase overall exacerbation risk, particularly in those with low blood eosinophil counts 1

3. Current guidelines: The 2023 Canadian Thoracic Society guidelines acknowledge that stepping down from triple therapy may be considered in appropriate patients 1

4. Dual bronchodilator efficacy: LAMA/LABA combination provides effective bronchodilation and exacerbation prevention without ICS-related adverse effects 1

Monitoring for Success or Failure

The withdrawal should be considered successful if:

• No increase in symptom burden
• No decline in lung function (FEV₁)
• No increase in exacerbation frequency

The withdrawal should be reconsidered if:

• Significant symptom worsening
• ≥100 mL decline in FEV₁
• Occurrence of moderate/severe exacerbations

Common Pitfalls to Avoid

1. Abrupt discontinuation: Always withdraw ICS gradually to minimize potential rebound effects

2. Inadequate monitoring: Close follow-up is essential during the withdrawal period

3. Ignoring patient-reported symptoms: Patient perception of symptom changes should guide decision-making alongside objective measures

4. Withdrawing during high-risk periods: Avoid initiating withdrawal during respiratory infection seasons or periods of poor air quality

5. Overlooking comorbidities: Patients with asthma-COPD overlap should generally continue ICS therapy

By following this evidence-based approach to ICS withdrawal, you can potentially reduce medication burden and adverse effects while maintaining disease control in this stable COPD patient with a low blood eosinophil count.