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

Management of ICS Withdrawal in Stable COPD with Low Blood Eosinophil Count

Gradually withdraw the ICS component while maintaining dual bronchodilator therapy with LAMA/LABA, as this patient with stable COPD, no exacerbations for over a year, and low blood eosinophil count (50 cells/μL) is at minimal risk for exacerbations following ICS withdrawal.

Patient Assessment and Risk Stratification

This 55-year-old male presents with:

• Stable COPD for >1 year with no exacerbations
• Current therapy: fluticasone/salmeterol 500/50 mcg BID and tiotropium 18 mcg daily
• Blood eosinophil count: 50 cells/μL (low)

Evidence-Based Approach to ICS Withdrawal

Blood Eosinophil Count as a Predictor

• Blood eosinophil count is a key predictor of response to ICS withdrawal
• Patients with counts <100 cells/μL (like this patient) have minimal risk of exacerbations following ICS withdrawal 1
• Post-hoc analysis of the WISDOM trial showed increased exacerbation risk only in patients with eosinophil counts ≥300 cells/μL or ≥4% of total WBC 2

Recommended Withdrawal Protocol

1. Gradual withdrawal approach (not abrupt discontinuation)

   • Start with 50% reduction in fluticasone dose for 6-8 weeks
   • Then complete discontinuation while maintaining dual bronchodilator therapy 1

2. Maintain dual bronchodilator therapy

   • Continue tiotropium 18 mcg once daily
   • Continue salmeterol component (50 mcg twice daily) 1

3. Close monitoring during withdrawal period

   • Schedule follow-up visits at 4-6 week intervals
   • Monitor for symptoms, lung function changes, and exacerbations 1

Monitoring Parameters During Withdrawal

Success Criteria

• No increase in symptom burden
• No significant decline in lung function (FEV₁)
• No increase in exacerbation frequency 1

Criteria to Reconsider ICS Withdrawal

• Significant symptom worsening
• ≥100 mL decline in FEV₁
• Occurrence of moderate/severe exacerbations 1

Important Considerations and Caveats

• The 2023 Canadian Thoracic Society guidelines support stepping down from triple therapy in appropriate patients 3
• Early studies suggesting harm from ICS withdrawal had methodological limitations and primarily examined abrupt discontinuation 4, 5
• The WISDOM trial demonstrated that gradual withdrawal of ICS does not increase overall exacerbation risk in patients with severe COPD, particularly those with low blood eosinophil counts 2
• Avoid initiating withdrawal during high-risk periods (respiratory infection seasons, poor air quality) 1
• LAMA/LABA combination provides effective bronchodilation and exacerbation prevention without ICS-related adverse effects 3, 1

Conclusion

This patient is an ideal candidate for ICS withdrawal based on:

1. Stable disease with no exacerbations for >1 year
2. Low blood eosinophil count (50 cells/μL)
3. Already on appropriate dual bronchodilator therapy

The evidence strongly supports a gradual withdrawal approach with close monitoring, which aligns with the findings of the WISDOM trial and current guidelines.