Inhaled corticosteroids should only be used as an add-on therapy in patients with COPD and their addition to LABA maintenance therapy in these patients must be personalised, agree international respiratory experts.

Tackling the much-debated topic of the efficacy, safety and positioning of ICS in the treatment of COPD, the group critically reviewed the evidence for and against ICS use in COPD and found that some patients may benefit from the addition of ICS to their LABA maintenance treatment whereas others don’t.

Therefore the risk to benefit ratio of adding (or withdrawing) ICS has to be carefully considered in each individual patient, they say.

The authors, including Dave Singh, Professor of Clinical Pharmacology and Respiratory Medicine at the University of Manchester, UK, stress that the challenge is how to identify what markers can help to identify in the clinic those COPD patients who can benefit most from ICS use at the lowest risk possible of undesired side effects.

They suggest a number of clinical and biological markers related to the benefits and risks of ICS in COPD can help clinicians to decide on their use in an individual patient.

They propose that patients most likely to benefit from the addition of ICS to long-acting bronchodilators include those with a history of multiple or severe exacerbations despite appropriate maintenance bronchodilator use, particularly if blood eosinophils are >300 cells/μL, and those with a history of and/or concomitant asthma.

They add: “Given that <100 eosinophils/μL seems a useful and reproducible threshold to predict a poor response to ICS in terms of  [exacerbations of COPD] prevention, we would suggest limiting their use in these patients, unless the individual patient has a history of asthma.”

The experts note there is an intermediate group of patients, with 100–300 eosinophils/μL, in whom current evidence is insufficient to make a firm recommendation. In this group, a careful consideration of the potential benefits and risks should be individually considered, they suggest.

Also proposed is that the risk of pneumonia in COPD patients using ICS is higher in those with older age, lower body mass index, greater overall fragility, receiving higher ICS doses and those with blood eosinophils <100 cells/μL.

“All these factors must be carefully considered and balanced in any individual COPD patient before adding ICS to her/his maintenance bronchodilator treatment,” Professor Singh and colleagues advised.

The review, published this month in ERJ Express, is not a systematic literature review but rather a narrative review based on the authors’ combined clinical experience and judgement, supported by selected references.

They note that further research is needed to clarify some of the issues and firmly establish these recommendations.