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Am Fam Physician. 2023;108(6):online

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Clinical Question

Does inhaled corticosteroid (ICS) monotherapy improve exacerbation outcomes in patients with stable chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

ICS monotherapy decreases the likelihood of exacerbations in patients with stable COPD compared with placebo.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

COPD is a pulmonary inflammatory condition characterized by airway obstruction.2 COPD affects more than 15 million people in the United States, causing more than 150,000 deaths per year.3 Primary care physicians need to recognize COPD and provide treatment to reduce exacerbations because of the related morbidity and socioeconomic burden. ICS monotherapy can benefit patients with COPD; however, its role is uncertain because recommendations have favored using ICS therapy in combination with long-acting bronchodilators.

The authors of this Cochrane review assessed studies published up to October 2022 that compared ICS monotherapy (commonly budesonide) vs. placebo in patients with stable COPD.1 Primary outcomes included COPD exacerbations, quality of life using the validated St. George’s Respiratory Questionnaire, all-cause mortality, lung function (e.g., forced expiratory volume in one second [FEV1]), use of rescue bronchodilators, exercise capacity, pneumonia, and thrush. Outcomes were measured by rates of hospitalization and oral corticosteroid and antibiotic use. This review included 36 randomized, double-blind, placebo-controlled trials with 23,139 participants. Most studies were conducted in the United States, Canada, Europe, and Africa in multicenter/hospital outpatient clinics. Outcomes were consistent among studies. The duration of follow-up was three to six months (17 studies) or more than six months to three years (19 studies). The standardization for using long-acting muscarinic antagonists/long-acting beta2 agonists or other treatments could not be reported.

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These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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