INHALED CORTICOSTEROIDS IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: AN OVERUSE?

Chronic obstructive pulmonary disease (COPD) patients have acute exacerbations that are associated with accelerated loss of lung function, impaired quality of life and enormous health-care costs. Prevention of exacerbations is a major therapeutic aim and, because inhaled corticosteroids (ICS) reduce exacerbations, their use is widespread in COPD patients. However, evidence has emerged linking ICS with increased risk of pneumonia in COPD. The aim of this review is to analyze the evidence about the benefits of the use of ICS in COPD and the risk of pneumonia. Literature review based on systematic reviews, meta-analysis and guidelines published in the last ten years in the Pubmed, Medscape and UptoDate databases, using the MeSH term "chronic obstructive pulmonary disease" and "inhaled corticosteroids." ICS used in combination with long-acting β2 agonists reduce exacerbations, improve lung function and quality of life. However, ICS are only recommended in patients included in GOLD C and D. Its use must be rational since ICS use by COPD patients increases the risk of serious pneumonia. There is an intra-class difference between fixed combinations of IC/long acting β2 agonist with regard to the risk of pneumonia. The risk is particularly more elevated and dose related with fluticasone than budesonide. In COPD patients at low risk of exacerbation, it was found that FEV1 and exacerbations history were similar in the patients treated with or without ICS. The withdrawal of ICS in this patients can be safe provided that patients are left on maintenance treatment with long-acting bronchodilators.