Cochrane for Clinicians
Putting Evidence into Practice
Use of Inhaled Corticosteroids to Treat Stable COPD
Am Fam Physician. 2008 Jun 1;77(11):1532-1533.
A 60-year-old patient with a 40 pack-year smoking history requests “something else” to treat his chronic cough and dyspnea from chronic obstructive pulmonary disease (COPD). He is already using an albuterol/ipratropium (Combivent) inhaler as needed.
Should inhaled corticosteroids be used to treat stable COPD?
Although the use of inhaled corticosteroids for COPD will not reduce mortality or affect long-term disease progression, inhaled corticosteroids can be useful for reducing COPD exacerbations and slowing declines in quality of life.
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
Table Recommendations for Diagnosis and Management of Stable COPD
Recommendations for Diagnosis and Management of Stable COPD
Spirometry should be performed to diagnose airflow obstruction in patients with respiratory symptoms (especially dyspnea); in asymptomatic patients, spirometry should not be used to screen for airflow obstruction
Reserve treatment for stable COPD to patients whose spirometry shows FEV1 less than 60 percent of predicted volume and who have respiratory Symptoms
For symptomatic patients with COPD and FEV1 less than 60 percent of predicted volume, one of the following maintenance monotherapies should be prescribed: a long-acting inhaled beta agonist; a long-acting inhaled anticholinergic; or an inhaled corticosteroid
For symptomatic patients with COPD and FEV1 less than 60 percent of predicted volume, consider combination inhaled therapies
For patients with COPD and resting hypoxemia (Pao2 ≤ 55 mm Hg [7.32 kPa]), prescribe oxygen therapy
In symptomatic patients with COPD who have an FEV1 less than 50 percent of predicted volume, consider prescribing pulmonary rehabilitation
COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in one second; Pao2 = arterial partial pressure of oxygen.
Information from reference 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.
Background: The role of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of inhaled corticosteroids. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.
Objectives: The objective of the review is to determine the effectiveness of the regular use of inhaled corticosteroids in patients with stable COPD.
Search strategy: A predefined search strategy was used to search the Cochrane Airways Group specialized register for relevant literature. Searches are current as of October 2006.
Selection criteria: The authors selected randomized trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta2 agonists and bronchial hyperresponsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. Data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers, and safety were also analyzed.
Data collection and analysis: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.
Main results: Forty-seven primary studies with 13,139 participants met the inclusion criteria. Medium-term use of inhaled corticosteroids (longer than two months and up to six months) resulted in a small improvement in FEV1 in some studies. Long-term use of inhaled corticosteroids (longer than six months) did not significantly reduce the rate of decline in FEV1 in patients with COPD (weighted mean difference [WMD] = 5.80 mL per year with inhaled corticosteroids over placebo; 95% confidence interval [CI], −0.28 to 11.88; 2,333 participants). There was no statistically significant effect on mortality in patients with COPD (odds ratio [OR] = 0.98; 95% CI, 0.83 to 1.16; 8,390 participants). Long-term use of inhaled corticosteroids reduced the mean rate of exacerbations in those studies where pooling of data was possible (WMD = −0.26 exacerbations per patient per year; 95% CI, −0.37 to −0.14; 2,586 participants). Inhaled corticosteroids slowed the rate of decline in quality of life, as measured by the St. George's Respiratory Questionnaire (WMD = −1.22 units per year; 95% CI, −1.83 to −0.60; 2,507 participants). Response to inhaled corticosteroids was not predicted by oral steroid response, bronchodilator reversibility, or bronchial hyperresponsiveness in patients with COPD. There was an increased risk of oropharyngeal candidiasis (OR = 2.49; 95% CI, 1.78 to 3.49; 4,380 participants) and hoarseness. The few long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years.
Authors' conclusions: Patients and physicians should balance the potential benefits of inhaled steroids in COPD (e.g., reduced rate of exacerbations, reduced rate of decline in quality of life) against the known increase in local side effects (e.g., oropharyngeal candidiasis, hoarseness). The risk of long-term adverse effects is unknown.
These summaries have been derived from Cochrane reviews published in the Cochrane Database of SystematicReviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the originalreviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minorediting changes have been made to the text (http://www.cochrane.org).
1. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–555.
2. Qaseem A, Snow V, Shekelle P, et al., for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;147(9):633–638.
3. Yang IA, Fong KM, Sim EHA, Black PN, Lasserson TJ. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007;(2):CD002991.
The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Dr. Cayley presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at http://www.cochrane.org/reviews/en/ab002991.html.
The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.
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