The Evolving Role of Inhaled Corticosteroids in COPD

Q:What is the latest thinking on the use of dailyinhaled corticosteroids in the managementof chronic obstructive pulmonary disease (COPD)?

Q:What is the latest thinking on the use of dailyinhaled corticosteroids in the managementof chronic obstructive pulmonary disease (COPD)?A:Although inhaled corticosteroids are the cornerstoneof maintenance therapy for moderate tosevere asthma, their use in COPD is controversial. Severalprospective, randomized, controlled clinical trials haveshown that inhaled corticosteroids do not significantlyslow the long-term progressive decline in forced expiratoryvolume in 1 second (FEV1) in patients with COPD.1-4Inflammatory mechanisms are part of the pathogenesisof both asthma and COPD; however, different cellularmediators and inflammatory cytokines are involved inthe two diseases. Nevertheless, systemic corticosteroidsare useful in severe exacerbations of COPD.5New evidence. More recent trials provide fairly compellingevidence that inhaled corticosteroids reduce thenumber and severity of exacerbations of both mild COPD2,3and moderate to severe disease (ie, FEV1 less than 50% ofpredicted).1 In one study, medium-or high-dose inhaledcorticosteroid therapy was associated with a significant reductionin mortality.6 In another study, the combinationof fluticasone and salmeterol was associated with decreasedmortality in patients with advanced COPD.7 Because ofthese new data, it is likely that the FDA will approve an indicationfor the use of fluticasone or the combination offluticasone and salmeterol as maintenance therapy inCOPD.Safety caveats. Inhaled corticosteroids may have systemicside effects. For example, the investigators in theLung Health Study found that triamcinolone was associatedwith reduced bone mineral density.2 (Other studies,however, have not shown this effect.8) In elderly patients,long-term use of high-dose inhaled corticosteroids hasbeen associated with cataracts.9 As with all corticosteroids,prescribe inhaled formulations only for specific indicationsand monitor patients regularly for adverse effects.The bottom line. Inhaled corticosteroids may beconsidered for long-term management in selected patients with moderate to severe COPD. However, these formulationsare not indicated for severe acute exacerbations ofCOPD because they are ineffective against peribronchialinflammation. Systemic corticosteroids are recommendedin this setting.




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