Appropriate use of ICS in COPD

GOLD treatment goals:

GOLD-treatment-goals

ICS-containing regimens are not recommended as initial maintenance therapy for the majority of COPD patients.*1

The GOLD 2017 Strategy Report recommends to initiate maintenance therapy in patients of all GOLD groups on ICS-free therapies. In patients with a history and/or findings suggestive of an asthma-COPD overlap, LABA/ICS may be considered as a first-choice option.1​

Safety risk of ICS

Clinical data show long-term ICS use is associated with an increased risk of various systemic and local side–effects2

Side-effects of inhaled corticosteroids in COPD and type of evidence2

side-effects-table

…carefully weigh the benefits of ICS use against the potential risk of side-effects and costs in individual patients with COPD

Price et al, Prim Care Respir J, 2013

*LABA/ICS may be the first choice in some patients. For example, those with a history and/or findings suggestive of asthma-COPD overlap.1

How does LAMA/LABA compare to LABA/ICS in patients at early stages of COPD in regards to lung function improvement?

Optimising lung function at the start of COPD therapy may help to keep patients engaged in their daily activities.3,4

In the ENERGITO study, the majority of patients (72%) had GOLD 2 lung function impairment. Patients who were treated with a LAMA/LABA (tiotropium/olodaterol) showed a significant improvement in lung function over the twice daily LABA/ICS (salmeterol/fluticasone).5

Improvement in FEV1AUC0-12

Improvement in FEV

Adapted from Beeh K-M, et al. Int J Chron Obstruct Pulm Dis 201611:193-205.

Limited benefit of ICS as COPD progresses

There is growing evidence that LAMA/LABA is more effective in major components of COPD compared with LABA/ICS (lung function, symptom control and reduction of exacerbation risk).5-7

The GOLD 2017 report recommends a more restricted use of ICS, even as COPD progresses. Even for GOLD D patients (patients that are symptomatic and have experienced ≥2 moderate or ≥1 severe exacerbation) the preferred option is a LAMA/LABA for both initiation and management. Only if further exacerbations occur on LAMA/LABA therapy, it is one option to escalate these patients to triple therapy, including ICS.1

In a 52-week study, the percentage of patients who had a clinically important decrease of at least 4 points in the total SGRQ-C score was significantly higher with a LAMA/LABA vs a LABA/ICS (49.2% vs 43.7% P<0.001).6

Limited use of ICS as COPD progresses

FLAME: Time to first exacerbation6

FLAME: Time to first exacerbation

Adapted from Wedzicha JA, et al. New Engl J Med 2016;374:2222-334.

Watch to learn about the superiority of LAMA/LABA to LABA/ICS in COPD shown in the ENERGITO® and FLAME studies

Which COPD patients may benefit from ICS use?

A post-hoc analysis of the WISDOM trial identified a subset of COPD patients who may derive increased benefit from adding ICS to their LAMA/LABA therapy.8​

Which patients will benefit from ICS use?

Watch the video below for more information on identifying COPD patients that may benefit from the addition of an ICS

References

  1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from:
    http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/ 
    [Accessed July 2017].
  2. Price D, et al. Prim Care Respir J. 2013;22(1):92-100.
  3. Ferguson GT, et al. Adv Ther. 2015;32:523-536 and supplementary information.
  4. Singh D, et al. Respir Res. 2016;17:73.
  5. Beeh K-M, et al. Int J Chron Obstruct Pulm Dis 2016;11:193-205.
  6. Wedzicha JA, et al. New Engl J Med 2016;374:2222-34.
  7. Vogelmeier C, et al. Int J Chron Obstruct Pulm Dis 2016;11:3189-97.
  8. Calverley PMA, et al. Am J Respir Crit Care Med 2017; doi 10.1164/rccm. 201612-2525LE