Inhaled corticosteroids are overused in patients with COPD and there is now clear evidence on which patients will most benefit, the European Respiratory Society 2020 virtual conference has heard.
But there is a danger that too much focus is given to inhaled steroid use at the risk of neglecting other aspects of COPD management that require improvement, said Professor James Chalmers, Professor of Respiratory Research at the University of Dundee.
Several studies have shown that inhaled steroids have traditionally been overused in COPD – with prescribing not following severity of disease or indications for use, Professor Chalmers told conference delegates.
This includes UK data showing that in 2005 more than three-quarters of patients with an FEV-1 above 50% and no history of exacerbation were prescribed an inhaled steroid containing therapy as their first prescription despite that never being recommended in any guidelines.
That had fallen to 47% by 2015 most notably after their use was shown to be associated with an increased risk of pneumonia, he said, but overuse has been shown to vary between regions in the UK.
Other studies have shown that patients reach treatment with triple therapy at the same rate regardless of exacerbation history.
“We’ve established the argument that there is a problem with inhaled corticosteroid prescribing and the solution has to be personalised medicine”, said Professor Chalmers who is the lead author on ERS guidelines on withdrawal of inhaled corticosteroids published in May.
The evidence is now pointing towards guiding treatment decisions using exacerbation history and blood eosinophil count as a guide, he said.
“I think there’s an increasing acceptance within the field that those with a low bloody eosinophil count are unlikely to benefit from inhaled corticosteroid and the benefit increases as blood eosinophil count increases.”
He added that inflammation was the key to deciding when to withdraw inhaled steroids given that the WISDOM trial had shown no increase in exacerbation and especially on closer analysis of different groups within that population.
“When you look in that population with bloody eosinophils above 300 you see a 30% increase in exacerbations between 300 and 400 and 73% increase when you get to above 400 cells. So the exacerbation history and bloody eosinophils tells us where the benefit risk becomes favourable for inhaled corticosteroids,” he said.
But he warned against getting too caught up in the discussion of how to make better targeted use of inhaled corticosteroids while neglecting other proven good practices in the management of COPD.
“There are not enough individuals taking up flu vaccination, not enough smoking cessation support, not enough access to pulmonary rehab and not enough initial bronchodilator therapy so I would make an overall call for better management of COPD in general.”