ICS use increases pneumonia incidence in COPD patients

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines COPD according to airflow limitation that is not fully reversible and abnormal inflammatory response of the lungs to noxious particles.  Inhaled corticosteroids (ICS) can decrease this inflammatory response but are not recommended for stable COPD as long-acting bronchodilators have more benefit with fewer adverse effects.  However, ICS are recommended in symptomatic COPD patients with frequent exacerbations who do not respond to treatment with inhaled bronchodilators, pulmonary rehabilitation, and smoking cessation.  ICS may also help COPD patients who appear to have an asthmatic component.

Regular treatment with ICS may improve symptoms, lung function, and quality of life.  ICS also reduce the frequency of COPD exacerbations in patients with FEV1 < 60% of predicted value.  Side effects include oral candidiasis, hoarse voice, skin bruising, and slightly increased risk of pneumonia.  There are conflicting studies regarding incidence of cataracts and diminished bone density.  Patients in those studies were also on systemic corticosteroids that may have increased the risk of cataracts and fractures.

The TORCH (TOwards a Revolution in COPD Health) trial showed that ICS use did not increase all-cause or cardiovascular mortality or incidence of lung cancer during a 3-year follow-up period.  However, monotherapy with ICS was associated with a small but statistically insignificant increase in mortality.  Hence, ICS should not be used alone but instead combined with a long-acting beta agonist.