Use of Inhaled Corticosteroids to Treat Stable COPD

American Family Physician

GOLD recommends long- and short-acting bronchodilators for day-to-day symptom control, with the addition of an inhaled corticosteroid for symptomatic patients with a forced expiratory volume in one second (FEV1) less than 50 percent of predicted volume.1 In contrast, the ACP recommends long-acting inhaled beta-agonists, long-acting inhaled anticholinergics, and inhaled corticosteroids as equally beneficial in reducing exacerbations.

Practice Pointers

Recent guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD)1 and the American College of Physicians (ACP)2 have addressed the management of stable COPD and recommend attention to four areas for individualized management of COPD: disease monitoring, risk factor reduction, management of stable COPD, and management of acute exacerbations. GOLD recommends long- and short-acting bronchodilators for day-to-day symptom control, with the addition of an inhaled corticosteroid for symptomatic patients with a forced expiratory volume in one second (FEV1) less than 50 percent of predicted volume.1

In contrast, the ACP recommends long-acting inhaled beta-agonists, long-acting inhaled anticholinergics, and inhaled corticosteroids as equally beneficial in reducing exacerbations. The ACP notes that bronchodilators and inhaled corticosteroids are similar in overall effectiveness, but differ somewhat in rates of adverse effects, reductions in hospitalizations, and mortality. The ACP recommendations for management of COPD are listed in the accompanying table.2

This Cochrane review provides additional clarification on the role of inhaled corticosteroids in COPD management.3 Inhaled corticosteroids do not appear to slow declines in the measures of lung function or to reduce rates of mortality from COPD, but they do appear to reduce the frequency of COPD exacerbations and to reduce declines in the measures of quality of life. The primary drawbacks to inhaled corticosteroids for COPD are local side effects and the lack of information on potential long-term adverse effects. Use of inhaled corticosteroids increases the risks of oropharyngeal complications, including hoarseness and oral candidiasis, although the latter may be avoidable with proper rinsing of the mouth after dosing. Currently, there is inadequate evidence to tell whether inhaled corticosteroids may reduce bone density, increase fractures, or cause other metabolic derangements over long-term (i.e., more than three years) therapy.

Because none of the available medications for COPD are able to modify long-term declines in lung function, individual treatment should be selected based on disease severity and the relative benefits and complications of different therapies. The lack of information on long-term adverse effects from inhaled corticosteroids may warrant caution in initiating inhaled corticosteroids for younger patients with less severe disease. Conversely, the benefit of inhaled corticosteroids to older patients with more severe disease may outweigh the potential for long-term adverse effects. In either case, patient education on proper inhaled corticosteroid use is important to help reduce the likelihood of local side effects.

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