What are the benefits and risks of inhaled corticosteroids for COPD?

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Clinical Inquiries

What are the benefits and risks of inhaled corticosteroids for COPD?

J Fam Pract. 2014 May;63(5):276-278

By

Tanya Hamilton, MD

John B. Miller, MD

E. Chris Vincent, MD

Leilani St. Anna, MLIS, AHIP

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References

1. Yang IA, Clarke MS, Sim EH, et al. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(7):CD002991.

2. Jones PW. St. George’s Respiratory Questionnaire: MCID. COPD. 2005;2:75-79.

3. Nannini LJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta(2)-agonist in one inhaler versus long-acting beta(2)-agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;9:CD006829.

4. Nadeem NJ, Taylor SJ, Eldridge SM. Withdrawal of inhaled corticosteroids in individuals with COPD—a systemic review and comment on trial methodology. Respir Res. 2011;12:107.

5. Qaseem A, Wilt TJ, Weinberger SE, et al; American College of Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-191.

6. Global Initiative for Chronic Obstructive Lung Disease Web site. Global strategy for the diagnosis, management and prevention of COPD. 2014. Available at: www.goldcopd.org/uploads/users/files/GOLD_Report2014_Feb07.pdf. Accessed April 4, 2013.

EVIDENCE-BASED ANSWER:

Inhaled corticosteroids (ICS), either alone or with a long-acting β agonist (LABA), reduce the frequency of exacerbations of chronic obstructive pulmonary disease (COPD) and statistically, but not clinically, improve quality of life (QOL) (strength of recommendation [SOR]: B, meta-analyses of heterogeneous studies).

However, ICS have no mortality benefit and don’t consistently improve forced expiratory volume in 1 second (FEV₁) (SOR: B, meta-analyses of secondary outcomes). They increase the risk of pneumonia, oropharyngeal candidiasis, and bruising (SOR: B, meta-analyses of secondary outcomes).

Withdrawal of ICS doesn’t significantly increase the risk of COPD exacerbation (SOR: B, a meta-analysis).

EVIDENCE SUMMARY

A Cochrane meta-analysis designed to determine the efficacy of ICS in patients with stable COPD found 55 randomized, controlled trials (RCTs) with a total of 16,154 participants that compared ICS with placebo for 2 weeks to 3 years duration.¹ COPD varied from moderate to severe in most studies.

In pooled data, ICS for 2 or more years didn’t consistently improve lung function, the primary outcome (TABLE). However, the largest RCT (N=2617) of 3 years duration showed a small decrease in decline of FEV₁ (55 mL compared with 42 mL, P value not provided). Regarding the secondary outcomes of mortality and exacerbations, ICS for a year or longer didn’t reduce mortality but decreased exacerbations by 19%.

Clinically significant adverse effects of ICS use included pneumonia, oropharyngeal candidiasis, and bruising; for ICS treatment longer than one year, the numbers needed to harm (NNH) compared with placebo were 30, 27, and 32, respectively. Bone fractures weren’t more common among ICS users. Investigators observed a statistical, but not clinical, QOL benefit as measured by the St. George’s Respiratory Questionnaire (SGRQ) in 5 RCTs with a total of 2507 patients (mean difference, ‒1.22 units/year; 95% confidence interval, ‒1.83 to ‒.60). The minimum clinically important difference on the 76-item questionnaire was 4 units.²

Evidence-based answers from the Family Physicians Inquiries Network

What are the benefits and risks of inhaled corticosteroids for COPD?

References

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