Minimising inhaled corticosteroids for COPD

This Therapeutic Letter considers the evidence for inhaled corticosteroids (ICS) as a treatment for Chronic Obstructive Pulmonary Disease (COPD). Drug therapy aims to alleviate symptoms, enhance functional capacity and prevent exacerbations, but has not consistently shown to reduce mortality or improve quality of life based on randomised trials.Inhaled corticosteroids have shown limited benefits for COPD symptoms and exacerbations but increased risks of serious harms. Guidelines recommend limiting ICS to severe COPD and only for repeated exacerbations. Studies show withdrawing ICS can be done safely for stable COPD patients with infrequent exacerbations, especially those with lower eosinophil counts. Provincial, national and international guidelines now recommend limiting ICS prescriptions to severe COPD stages. Long-term ICS use may lead to serious side effects, including pneumonia and fractures. Initial COPD therapy should focus on short-acting bronchodilators, not ICS. Adding long-acting bronchodilators is recommended before considering ICS because of limited benefits and risks of serious harms. For persistent symptoms, long-acting muscarinic antagonists (LAMA) or long-acting beta2 agonists (LABA) are recommended, with the addition of ICS reserved for those with repeated exacerbations and severe COPD. Deprescribing ICS can be considered in clinically stable patients, particularly for those with infrequent exacerbations and mild COPD. When applicable, tapering ICS over several months is advised for patients with elevated eosinophil counts. Overall, the risks of serious harms from ICS typically outweigh their limited benefits for mild COPD patients in primary care.