Effect of Discontinuing Inhaled Corticosteroids in Patients with COPD in Real Clinical Practice

Introduction

Long-acting muscarinic antagonists (LAMAs) and long-acting β₂-agonists (LABAs) play a crucial role in the treatment of COPD, either as monotherapy or in combination therapy. For patients with persistent exacerbations despite optimal bronchodilator therapy, inhaled corticosteroids are recommended as an addition, especially if they also have eosinophilia or a history of bronchial asthma.

Adding a corticosteroid to LAMA and LABA is referred to as triple therapy. This has demonstrated superiority over dual therapy in several randomized controlled clinical trials. However, more recent findings suggest that patients recruited for these studies do not accurately reflect the characteristics of common patients in primary care. Based on the results of published studies, inhaled corticosteroids are often overprescribed.

Study Design and Objectives

The intention of the authors of a recently published study conducted in primary care settings was to clarify the effect of discontinuing inhaled corticosteroids in patients with COPD, compared to continuing triple therapy. Inhaled corticosteroid therapy was discontinued in 1,046 patients, who were matched in a 1:4 ratio to 4,184 patients continuing on triple therapy.

The effect of discontinuing inhaled corticosteroids was evaluated after one year of follow-up. The primary objective of the study was to determine the time to first disease exacerbation, with up to 76.1% of the overall population having observed no or one COPD exacerbation in the previous year.

There were no significant differences between the groups in terms of age and gender distribution, smoking, and time since COPD diagnosis.

Results

There was no increased risk of moderate to severe COPD exacerbation in patients who discontinued inhaled corticosteroids compared to the control group (adjusted hazard ratio [HR] 1.04; 95% confidence interval [CI] 0.94–1.15; p = 0.441). Both groups had similar rates of at least one episode of exacerbation (47.9% vs. 48.0%).

Patients who discontinued inhaled corticosteroids showed a slight increase in the incidence of COPD exacerbations treated within primary care (incidence rate ratio [IRR] 1.33; 95% CI 1.10–1.60; p = 0.003) or leading to hospitalization (IRR 1.72; 95% CI 1.03–2.86; p = 0.036). Failure to discontinue inhaled corticosteroids was significantly and independently associated with more frequent prescriptions of oral corticosteroids in the previous year and a blood eosinophil count ≥ 300/μl. There was no significant difference in the annual change in FEV₁.

Conclusion

The results of the study conducted in primary care settings consisting mostly of patients without frequent exacerbations showed that discontinuing inhaled corticosteroids was not associated with a higher risk of COPD exacerbations compared to triple therapy. In line with current recommendations, the study confirmed that inhaled corticosteroid therapy should not be discontinued in patients with more frequent prescriptions of oral corticosteroids for COPD exacerbations in recent years and those with high blood eosinophil counts.

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Source: Magnussen H., Lucas S., Lapperre T. et al.; Respiratory Effectiveness Group (REG). Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study. Respir Res 2021 Jan 21; 22 (1): 25, doi: 10.1186/s12931-021-01615-0.