National Heart and Lung Institute, Imperial College London, London, UK.
Lung Unit, Emek Medical Center, Afula, Israel.
NPJ Prim Care Respir Med. 2023 Jul 24;33(1):27. doi: 10.1038/s41533-023-00347-6.
Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.
吸入性皮质类固醇（ICS）是治疗哮喘的主要方法，但它们在慢性阻塞性肺疾病（COPD）中的作用仍存在争议。最近在 COPD 患者和频繁或严重加重的患者中进行的随机对照试验（RCT）表明，ICS 联合双支气管扩张剂治疗（三联疗法）可显著减少约 25%的加重。然而，欧洲药品管理局和美国食品和药物管理局此后拒绝了与这些试验中 ICS 相关的死亡率益处的建议。来自常规临床实践的观察证据表明，在广泛的 COPD 患者人群中，双支气管扩张与频繁或严重加重和高血嗜酸性粒细胞（~10%的 COPD 人群）或伴有哮喘的患者相比，与三重疗法相比，与更好的临床结果相关。然而，常规临床实践的数据表明 ICS 被过度使用，多达 50-80%的患者开了 ICS。在不符合指南标准的患者中开具 ICS 会使患者面临不必要的肺炎和其他长期不良事件的风险，并且也会产生成本影响，而在疾病控制方面没有任何明显的益处。在本文中，我们回顾了 ICS 在 COPD 中的使用的益处和风险，从初级保健中进行的 RCT 和观察性研究中汲取证据。我们还根据最新的全球治疗指南提供了开具 ICS 的实用指南，以帮助初级保健提供者识别出 ICS 受益大于风险的患者。
