Is Inhaled Corticosteroid (ICS) recommended or contraindicated in Chronic Obstructive Pulmonary Disease (COPD) patients with multiple infectious exacerbations per year?

ICS Therapy in COPD Patients with Multiple Infectious Exacerbations

Inhaled corticosteroids (ICS) are recommended, not contraindicated, in COPD patients with multiple infectious exacerbations per year, particularly when used in combination with long-acting bronchodilators. 1

Patient Selection for ICS Therapy

ICS therapy is specifically indicated for COPD patients with:

• History of two or more exacerbations in the previous year 1
• Patients at high risk for exacerbations despite appropriate bronchodilator therapy 1, 2
• Blood eosinophil counts ≥300 cells/μL (stronger indication) 1, 2
• Severe airflow obstruction (FEV1 <50-60% predicted) 1

Optimal Treatment Approach

First-line approach:

• ICS should always be used in combination with long-acting bronchodilators, never as monotherapy 1
• Triple therapy (LAMA/LABA/ICS) is preferred for patients with multiple exacerbations 1
• Single-inhaler triple therapy shows incremental benefit compared to multiple-inhaler therapy 1

For patients with continued exacerbations despite triple therapy:

1. Consider adding macrolide maintenance therapy (in patients with normal QT interval, no significant drug interactions, and no evidence of atypical mycobacterial infection) 1
2. For patients with chronic bronchitic phenotype, consider adding roflumilast or N-acetylcysteine 1

Benefits vs. Risks

Benefits:

• 24% reduction in moderate/severe exacerbations compared to LAMA/LABA therapy 1
• Potential mortality benefit with moderate-dose ICS triple therapy 1
• Number needed to treat: 4 patients for 1 year to prevent one moderate to severe exacerbation 1

Risks:

• Increased pneumonia risk, especially in severe disease 1, 2
• Number needed to harm: 33 patients for 1 year to cause one pneumonia 1
• Other potential side effects: oral candidiasis, hoarseness, dysphonia, and bruising 2

Important Considerations

• Moderate doses of ICS are generally sufficient; high doses increase adverse effects without significant additional benefit 1
• Budesonide may be preferred over fluticasone in patients with higher pneumonia risk (relative risk 0.86) 2
• Withdrawing ICS can lower health status, lung function, and increase exacerbation risk, particularly in patients with blood eosinophils ≥300 cells/μL 1, 3
• European Respiratory Society strongly recommends against withdrawing ICS in patients with blood eosinophil counts ≥300 cells/μL 3

Monitoring Recommendations

• Regular follow-up to assess exacerbation frequency, development of pneumonia, and symptom control 2
• Re-evaluate treatment after 4-8 weeks to determine efficacy 2
• Consider the balance between pneumonia risk and exacerbation reduction benefits 1, 2

In conclusion, despite the increased pneumonia risk, the benefits of ICS therapy in reducing exacerbations, improving quality of life, and potentially reducing mortality in COPD patients with multiple exacerbations outweigh the risks when used appropriately in the right patient population.