Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today?

ABSTRACT

Introduction

As of today, there is still a need to determine which COPD patients may benefit from ICS therapy, whether ICSs are useful in COPD patients without chronic bronchitis, and whether long-acting bronchodilators can reduce the risk of exacerbations in frequent exacerbators even if ICSs are not used, and whether combination therapy including ICSs is helpful in infrequent exacerbators to optimize the use of ICSs in COPD.

Areas covered

Herein, the authors provide an overview of use of ICS in COPD, discuss their value to the current treatment armamentarium and focus on emerged aspects on which there is no consensus.

Expert opinion

There is growing agreement on why, in whom, and when ICS therapy can be used in COPD, although the consensus is still lacking because of the heterogeneity of COPD. The use of BECs is only helpful in T2 inflammation, while there is a lack of biomarkers indicating the presence of T1 and T17 immunity, which is poorly responsive to ICS. Identifying ICS-sensitive endotypes using specific biomarkers that have yet to be identified and validated is likely to demonstrate that ICSs can influence the natural course of COPD in at least a subset of patients.

KEYWORDS:

• COPD
• inhaled corticosteroids
• blood eosinophil count
• exacerbation
• pneumonia
• mortality
• phenotype

Article highlights

• ICSs are overprescribed in COPD patients probably because physicians are influenced more by the clinical characteristics of the individual patient than by guideline recommendations.

• The current opinion is to reserve the use of ICSs for the COPD subgroup characterised by the presence of T2 inflammation identifiable on the basis on blood eosinophilia (≥300 cells/μL) and a high level of FeNO fraction (≥ 35 ppb).

• The protection against exacerbations exerted by the addition of ICSs appears to be greater in the presence of a high BEC (mainly ≥300 cells/μL). In contrast, BEC does not influence the impact of ICS on lung function.

• ICSs may induce some level of cardioprotection, reduce the likelihood of developing lung cancer, and have a beneficial impact on survival in patients with COPD.

• Several studies have suggested a link between the long-term use of ICSs and the risk of pneumonia in patients with COPD. The risk of pneumonia seems to be greater in COPD patients with lower BECs.

• Although interruption of an ICS treatment in patients with COPD is not a common practice, de-escalation of ICS can be performed without any serious problems if it is carried out in the right patient, who must, in any case, be immediately treated appropriately with long-acting bronchodilators, possibly in combination.

This box summarizes key points contained in the article.

Declaration of Interest

M Cazzola has served as a faculty member and advisor for scientific meetings sponsored by Abdi Ibrahim, Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi Farmaceutici, Cipla, Edmond Pharma, GlaxoSmithKline, Glenmark, Lallemand, Menarini Group, Mundipharma, Novartis, Pfizer Inc, Teva Pharmaceuticals, Verona Pharma, and Zambon and is or was a consultant for ABC Farmaceutici, AstraZeneca, Chiesi Farmaceutici, Edmond Pharma, Lallemand, Novartis, Ockham Biotech, Verona Pharma and Zambon. J Ora has participated as a speaker in scientific meetings and courses under the sponsorship of AstraZeneca, Boehringer Ingelheim, Chiesi Farmaecutici, GlaxoSmithKline, Menarini Group, and Novartis. L Calzetta meanwhile has participated as an advisor in scientific meetings sponsored by Boehringer Ingelheim, and Novartis and Almirall and is or was a consultant to ABC Farmaceutici, Recipharm, Zambon, Verona Pharma and Ockham Biotech. Almirall, Boehringer Ingelheim, Chiesi Farmaceutici, Novartis, and Zambon furthermore fund their department. P Rogliani reports grants and personal fees from Almirall, AstraZeneca, Biofutura, Boehringer Ingelheim, Chiesi Farmaceutici, GlaxoSmithKline, Menarini Group, Mundipharma, and Novartis and participated as a lecturer and advisor in scientific meetings sponsored by Almirall, AstraZeneca, Biofutura, Boehringer Ingelheim, Chiesi Farmaceutici, Edmond Pharma, GlaxoSmithKline, Menarini Group, Mundipharma and Novartis. Almirall, Boehringer Ingelheim, Chiesi Farmaceutici, Novartis and Zambon fund her her department. Finally, MG Matera has participated as a faculty member and advisor in scientific meetings sponsored by ABC Farmaceutici, Almirall, AstraZeneca, Chiesi Farmaceutici, GlaxoSmithKline and Novartis and was a consultant to Chiesi Farmaceutici, and GlaxoSmithKline. Furthermore, GlaxoSmithKline and Novartis have funded her department. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One reviewer has received sponsorship to attend and speak at international meetings, honoraria for lecturing or attending advisory boards, and research grants from the following companies: Aerogen, AstraZeneca, Boehringer Ingelheim, Chiesi Farmaceutici, Cipla, CSL Behring, Epiendo, Genentech, GlaxoSmithKline, Glenmark, Gossamerbio, Kinaset, Menarini Group, Novartis, Pulmatrix, Sanofi, Synairgen, Teva Pharmaceuticals, Theravance and Verona Pharma. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript was not funded.