Inhaled corticosteroids in COPD: a case in favour

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease, which is characterised by reduced post-bronchodilator lung function in all patients 1. Although hyperresponsiveness and acute bronchodilator reversibility have been regarded as characteristics of asthma, it is now generally acknowledged that these clinical features are also present in COPD. Results as high as 39–66% for reversibility 2, dependent on the method of expression, and 60% for hyperresponsiveness, as measured with methacholine, have been reported. Patients generally show progressive lung function loss, accompanied by worsening respiratory symptoms and health status 1. These clinical features are associated with airway inflammation, i.e. bronchial infiltration of neutrophils, macrophages, lymphocytes, and mast cells 3–5. Smoking accelerates lung function loss and increases mortality in COPD, and smoking cessation has consistently been shown to improve these outcomes. Other risk factors for a worse prognosis include higher age, female sex, airway hyperresponsiveness, sputum production, underweight and frequent exacerbations 1. As well as smoking cessation, it is logical to investigate whether treatment that changes these risk factors and/or their underlying mechanisms can also change the long-term outcome of COPD. Many studies have assessed the long-term benefits of available COPD treatments, such as inhaled corticosteroids (ICS), long-acting β2-agonists (LABA) and long-acting anticholinergics. As a result, current guidelines recommend treatment with ICS for patients with severe COPD and frequent exacerbations, in addition to long-acting bronchodilators for patients with moderate-to-severe COPD 1. Below we summarise evidence advising the use of ICS or ICS+LABA in COPD from double-blind studies with intermediate (1–2 yrs) and long-term (>2 years) follow-up. It is now clear that regular anti-inflammatory treatment with ICS improves symptoms, health status and forced expiratory volume in 1 s (FEV1) while decreasing exacerbation rates 6–9. Withdrawing ICS (under protection of LABA) in …