Inhaled Corticosteroids in Moderate-to-Severe COPD
For adults with moderate-to-severe COPD, add inhaled corticosteroids (ICS) when patients have ≥2 moderate exacerbations or ≥1 severe exacerbation in the previous year despite appropriate bronchodilator therapy, particularly if blood eosinophils are >300 cells/μL. 1
When to Add ICS: Exacerbation Thresholds
ICS should be added when patients experience ≥2 moderate exacerbations or ≥1 severe exacerbation per year despite optimal bronchodilator therapy. 1 This represents the clearest evidence-based threshold from the American Thoracic Society guidelines.
ICS are recommended when airflow obstruction is severe or very severe (FEV1 <50% predicted) AND there is a history of frequent exacerbations. 2 This older ACCP guideline provides the lung function threshold that complements the exacerbation frequency criterion.
Patients with FEV1 <60% predicted and activity-limiting dyspnea may benefit from triple therapy including ICS. 1 The GOLD criteria suggest considering ICS at this slightly higher FEV1 threshold when symptoms are prominent.
Blood Eosinophil Count Thresholds
Blood eosinophils serve as a critical biomarker for predicting ICS response:
Patients with eosinophils >300 cells/μL have the strongest predicted response to ICS therapy. 1, 3 This threshold identifies those most likely to benefit from ICS addition.
Patients with eosinophils 150-300 cells/μL show moderate benefit from continued ICS treatment (rate ratio 0.80 for exacerbation reduction). 4 This intermediate range suggests ICS may still be beneficial but with less robust effect.
Patients with eosinophils <150 cells/μL show minimal benefit from ICS (rate ratio 0.88) and should generally not receive ICS. 4 This low eosinophil count identifies patients unlikely to benefit and at higher risk for pneumonia. 3
Patients with eosinophils <100 cells/μL have increased risk of pneumonia with ICS use and should avoid these medications. 3 This represents a clear contraindication threshold.
Recommended ICS Dosing Regimens
ICS should never be used as monotherapy in COPD—always combine with long-acting bronchodilators: 3
First-line ICS regimen: Combination ICS/LABA therapy (such as fluticasone/salmeterol or budesonide/formoterol) is recommended over ICS monotherapy. 2 This dual therapy reduces exacerbations more effectively than either agent alone.
Triple therapy regimen: ICS/LAMA/LABA (such as budesonide/glycopyrrolate/formoterol) is recommended for patients with severe COPD who have persistent exacerbations despite dual bronchodilator therapy. 1 Triple therapy reduces all-cause mortality risk compared to dual bronchodilator therapy alone. 1
For high-dose ICS (≥1,000 μg/day), use a large-volume spacer or dry-powder system to optimize delivery and reduce oral side effects. 2
Critical Safety Considerations
The pneumonia risk with ICS must be carefully weighed against exacerbation reduction benefits:
All ICS-containing regimens increase pneumonia risk, particularly in older patients and those with lower BMI. 1 This represents the most significant adverse effect of ICS therapy.
The number needed to treat with triple ICS therapy to prevent one moderate-to-severe exacerbation is 4 patients for 1 year, while the number needed to harm (cause one pneumonia) is 33 patients for 1 year. 1 This favorable risk-benefit ratio supports ICS use in appropriate patients.
Higher pneumonia risk occurs in patients with older age, lower BMI, greater overall fragility, higher ICS doses, and blood eosinophils <100 cells/μL. 3 These factors should prompt reconsideration of ICS therapy.
Monitoring Requirements
Patients on ICS require systematic monitoring:
Regular assessment for pneumonia signs and symptoms is necessary. 1 This should occur at every clinical encounter given the increased risk.
Monitor blood glucose levels and screen for oral candidiasis periodically. 1 These represent common ICS-related complications requiring surveillance.
Reassess the need for continued ICS therapy if patients have moderate COPD with no history of frequent exacerbations. 5 ICS may be safely withdrawn in this population while maintaining adequate bronchodilator therapy.
Common Pitfalls to Avoid
ICS are frequently overprescribed in COPD—up to 75% of COPD patients receive ICS despite only 20% having severe to very severe disease that warrants their use. 6 This represents a major quality gap in COPD management.
Do not use ICS as first-line maintenance therapy. 6 Maximal bronchodilation with LABA/LAMA combinations should precede ICS addition in most patients.
Do not continue ICS in patients with blood eosinophils <150 cells/μL unless there is concomitant asthma. 3, 4 This population derives minimal benefit and faces increased pneumonia risk.