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Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease

¹ Division of Clinical Epidemiology, Royal Victoria Hospital, McGill University Health Centre, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, Canada; ² Division of Pulmonary Sciences and Critical Care Medicine, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado; ³ Veterans Affairs Medical Center, University of Minnesota, Minneapolis, Minnesota; and ⁴ Division of Pulmonary Sciences and Critical Care Medicine, National Jewish Medical and Research Center, University of Colorado School of Medicine, Denver, Colorado

Correspondence and requests for reprints should be addressed to Barry Make, M.D., National Jewish Medical and Research Center, 1400 Jackson Street, J211, Denver, CO 80206. E-mail: makeb{at}njc.org

ABSTRACT

The effectiveness of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Randomized controlled trials, meta-analyses, medication withdrawal studies, and observational reports have examined this question, with mixed results. Observational studies have been subject to criticism because of study design involving immortal time bias. Some randomized controlled trials suggest small benefits in lung function and health status, and a reduction in the rate of acute exacerbations of COPD and mortality, but their incomplete follow-up and statistical methods have been criticized. The greatest benefits of ICS in COPD have been reported with use of ICS and long-acting ß-agonist combination therapy, although no benefit was found for the primary outcome studied under the most rigorous methodology by the recent TORCH and Optimal randomized trials. Thus, although future randomized trials will need to be conducted with the most rigorous methodology for all outcomes, much uncertainty remains regarding the potential benefits of ICS in COPD.

Key Words: chronic obstructive pulmonary disease • inhaled corticosteroids • beta-agonist bronchodilators • survival • quality of life

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