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A spotlight on Inhaled Corticosteroids

Key takeaways

  • ICS use in COPD has the potential to reduce exacerbations 1
  • However it is associated with side effects, including pneumonia and this must be balanced against the benefits of ICS 1
  • Therefore it's key to have a discussion with your patient, as ICS use must be personalised 2

When should you consider the use of ICS?

According to GOLD:1

  • ICS/long-acting beta agonist (LABA) combination therapy is more effective than the individual components in improving lung function, health status and reducing exacerbations in patients with moderate to very severe COPD. 1
  • Combining ICS with a long-acting muscarinic antagonist (LAMA)/LABA in a triple therapy is more effective in patients with high exacerbation risk compared with a LAMA/LABA dual therapy.1,3
According to NICE:4

  • LAMA/LABA is recommended for patients who remain breathless or have exacerbations despite using a short acting bronchodilator
  • ICS/LABA is recommended for patients with COPD and asthmatic features/features suggesting steroid responsiveness and LAMA/LABA is recommended in patients without these features
  • ICS/LAMA/LABA is recommended for patients with COPD and asthmatic features/features suggesting steroid responsiveness, who remain breathless or have exacerbations despite taking ICS/LABA
  • Importantly, the risk of side effects, including pneumonia, should be discussed with patients who take ICS as part of their COPD therapy

Clinical trial evidence suggests that ICS is associated with a higher prevalence of:1 oral candidiasis, hoarse voice, skin bruising, pneumonia.

But other factors that can increase the risk of pneumonia in patients taking ICS therapies include:1
  • Current smokers
  • Aged ≥55 years
  • Have a history of exacerbations or pneumonia
  • Body mass index <25 kg/m2
  • Poor Medical Research Council (MRC) dyspnoea grade and/or severe airflow limitation
Talk to your patient about modifiable factors such as smoking and an optimum BMI which can reduce the risk of pneumonia.

Who is most likely to benefit from ICS use?

According to GOLD, a blood eosinophil count threshold of > 300 cells per μL is recommended as a predictive measure to identify patients with the greatest likelihood of benefit from ICS-containing therapies.1

Remember, once treated with ICS-containing therapies, it is unclear if ICS withdrawal will lead to an increase in exacerbations and/or symptoms.1

So in summary is ICS suitable for my patient?

COPD treatment should be personalised to every patient to assess whether the benefits of ICS-containing regimens outweigh the risks.

Considerations for ICS use are summarised below and can help guide you when making a decision about ICS.  

A guide to whether ICS should be initiated in COPD. This guide does not apply to withdrawal 2
Likely to benefit Consider use Avoid use
▪️  ≥2 moderate exacerbations/year* ▪️  1 moderate exacerbation/year* ▪️  Repeated pneumonia events
▪️  History of hospitalisation(s) for exacerbation* ▪️  Blood eosinophils 100-300 cells/μL ▪️  Blood eosinophils <100 cells/μL
▪️  Blood eosinophils >300 cells/μL ▪️  History of mycobacterial infection
▪️  History of asthma or currently asthmatic
* Despite appropriate long-acting bronchodilator maintenance therapy. Adapted from Agusti et al 2018 2


  1. GOLD. Gold Initiative For The Diagnosis, Management, And Prevention of Chronic Obstructive Pulmonary Disease (2019 Report). 2019.
  2. Agusti A, Fabbri LM, Singh D, et al. Inhaled corticosteroids in COPD: Friend or foe? Eur Respir J. 2018;52(6). 
  3. Lipson DA, Barnhart F, Brealey N, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med. 2018. 
  4. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2018

PM-GB-CPU-WCNT-190002 - March 2019

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