Should an inhaled corticosteroid (ICS) be started in a patient with chronic obstructive pulmonary disease (COPD) and a history of exacerbations, despite adherence to formoterol (long-acting beta-agonist)/aclidinium (long-acting muscarinic antagonist), to reduce the risk of future exacerbations?

ICS Therapy in COPD with History of Exacerbations

An inhaled corticosteroid (ICS) should be started in this patient to reduce his risk of future exacerbations, despite his low blood eosinophil count. 1

Assessment of Current Status

This 65-year-old male patient presents with:

• History of two COPD exacerbations in the past year
• Current treatment: formoterol/aclidinium (LABA/LAMA) combination
• Blood eosinophil count: 125 cells/µL
• Comorbidities: hypertension, dyslipidemia, coronary artery disease
• Former smoker with no history of asthma or allergies

Rationale for ICS Addition

Exacerbation History

• The patient has experienced two exacerbations in the past year despite being on dual bronchodilator therapy (LABA/LAMA)
• According to guidelines, patients with frequent exacerbations despite appropriate bronchodilator therapy are candidates for ICS addition 1
• The American College of Chest Physicians and Canadian Thoracic Society strongly recommend maintenance combination ICS/LABA therapy to prevent acute exacerbations (Grade 1C) 2

Blood Eosinophil Considerations

• While the patient's eosinophil count is relatively low (125 cells/µL), the primary indication for ICS is his exacerbation history
• The greatest benefit of ICS is typically seen in patients with eosinophil counts >300 cells/µL, but patients with frequent exacerbations may benefit regardless of eosinophil count 1, 3
• The risk-benefit ratio still favors ICS addition in this case due to the continued exacerbations on dual bronchodilator therapy

Treatment Approach

1. Add ICS to current LABA/LAMA therapy:

   • Escalate to triple therapy (LABA/LAMA/ICS) as supported by ERS/ATS guidelines for patients with a history of exacerbations 1
   • This approach is consistent with GOLD recommendations for patients who continue to experience exacerbations despite dual bronchodilator therapy

2. ICS Selection Considerations:

   • Consider budesonide over fluticasone due to potentially lower pneumonia risk, especially given the patient's COPD and age 1
   • Start with a moderate dose to balance efficacy and safety

Monitoring and Follow-up

• Regular follow-up to assess:

  • Exacerbation frequency
  • Development of pneumonia (higher risk with ICS)
  • Symptom control
  • Adverse effects

• Re-evaluate treatment after 4-8 weeks to determine efficacy 1

Addressing Potential Concerns

Pneumonia Risk

• While there is an increased risk of pneumonia with ICS therapy (particularly in older patients), this risk should be balanced against the established benefits in reducing exacerbations 1, 3
• The patient's history of multiple exacerbations outweighs the potential pneumonia risk

Low Eosinophil Count

• Although patients with higher eosinophil counts (>300 cells/µL) typically show greater response to ICS, the patient's exacerbation history despite optimal bronchodilator therapy is the primary indication for ICS addition 1, 3
• The continued exacerbations despite dual bronchodilator therapy suggest that additional anti-inflammatory treatment is needed

Common Pitfalls to Avoid

1. Not escalating therapy despite continued exacerbations: Continuing with the same therapy when a patient is experiencing exacerbations is suboptimal care

2. Focusing solely on eosinophil count: While eosinophil count is important, exacerbation history is equally critical in determining the need for ICS

3. Overlooking pneumonia risk: Regular monitoring is essential to detect early signs of pneumonia, especially in this older patient with COPD

4. Using ICS as monotherapy: ICS should always be combined with long-acting bronchodilators in COPD, never as monotherapy 2, 3