From the Guidelines
For patients with stable moderate to very severe COPD, combination inhaled corticosteroid/long-acting beta-agonist therapy is recommended over inhaled corticosteroid monotherapy to prevent acute exacerbations of COPD. This approach is based on the guidelines from the American College of Chest Physicians and Canadian Thoracic Society, as outlined in a 2015 study published in the journal Chest 1. The use of inhaled corticosteroids (ICS) in Chronic Obstructive Pulmonary Disease (COPD) is aimed at reducing airway inflammation, which in turn helps decrease the frequency of exacerbations and improve quality of life.
Key considerations for the use of ICS in COPD include:
- Patient selection: ICS therapy should be considered for patients with frequent exacerbations or those with overlapping asthma features.
- Combination therapy: ICS are typically prescribed in combination with long-acting bronchodilators such as long-acting beta-agonists (LABAs) or with both LABAs and long-acting muscarinic antagonists (LAMAs) in triple therapy.
- Monitoring: Patients on ICS should be monitored for potential side effects including oral candidiasis, hoarse voice, and increased pneumonia risk.
- Inhaler technique: Proper inhaler technique is essential for the effectiveness of ICS therapy, and patients should rinse their mouth after use to minimize oral side effects.
The benefits of ICS in COPD management are significant, particularly in reducing exacerbation frequency, which is a major determinant of morbidity, mortality, and quality of life in these patients. While ICS have a lesser impact on lung function decline compared to their effects in asthma, their role in managing COPD, especially in preventing acute exacerbations, is well-established, as recommended by the guidelines 1.
From the Research
Guidelines for Using Inhaled Corticosteroids in COPD
- The use of inhaled corticosteroids (ICS) in combination with long-acting beta-agonists (LABAs) is common in the treatment of Chronic Obstructive Pulmonary Disease (COPD) 2.
- Studies have compared the effectiveness of different ICS/LABA combinations, including budesonide/formoterol, beclomethasone/formoterol, fluticasone/vilanterol, and fluticasone/salmeterol 2.
- Current evidence suggests that budesonide/formoterol may be associated with a lower incidence of serious pneumonia events and oral candidiasis compared to other LABA/ICS combinations 2.
- For patients with one or two COPD exacerbations per year, adding an inhaled corticosteroid (such as beclomethasone, budesonide, or fluticasone) to a long-acting beta-2 agonist may prevent about 1 exacerbation during 3 to 4 years of treatment 3.
- However, inhaled corticosteroids can cause adverse effects such as pneumonia, candidiasis, dysphonia, and adrenal insufficiency, with fluticasone seeming to have more adverse effects than other inhaled corticosteroids 3.
Comparative Effectiveness of Different ICS/LABA Combinations
- A real-world comparative effectiveness study found that fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) was associated with a significantly lower rate and risk of COPD exacerbations compared to budesonide/glycopyrrolate/formoterol fumarate (BUD/GLY/FORM) 4.
- Another study found that budesonide-based triple therapy was generally as effective as fluticasone-based triple therapy in reducing exacerbations, but was associated with a lower incidence of severe pneumonia and possibly also of all-cause death 5.
- A randomized controlled trial found that budesonide/formoterol maintenance and reliever therapy (MART) was similarly effective to fluticasone/salmeterol fixed-dose therapy in reducing exacerbations, but with a lower daily ICS dosage 6.
Key Considerations for ICS Use in COPD
- The choice of ICS/LABA combination should be based on individual patient characteristics and medical history 2, 3.
- Patients with COPD should be monitored regularly for adverse effects and exacerbations, and their treatment regimen should be adjusted as needed 3, 4, 5, 6.
- Further research is needed to fully understand the effectiveness and safety of different ICS/LABA combinations in COPD, particularly in terms of long-term outcomes and rare adverse effects 2, 6.