Pro: Inhaled corticosteroids for chronic obstructive pulmonary disease

Background: Controversy exists about the use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD). Although ICS are not approved as monotherapy for COPD, four ICS molecules, beclomethasone, budesonide, fluticasone furoate, and fluticasone propionate, are used widely in combination with long-acting bronchodilators to treat patients with this disease. Objectives: (1) To review the mechanisms of action of ICS therapy that contribute to the clinical benefits in COPD; and (2) to describe improvements in lung function, relief of dyspnea, increase in exercise tolerance, and the reduction in exacerbations with ICS use in COPD. Methods: A critical review of phase III and IV randomized clinical trials that evaluated ICS therapy in patients with COPD. Results: ICS have two major mechanisms of action in human airways: a reduction in edema and inflammation, and a decrease in airway hyperresponsiveness. ICS monotherapy significantly increases the morning peak expiratory flow rate and forced expiratory volume in 1 second (peak and trough) as early as the first day of treatment. Discontinuation of ICS therapy leads to deterioration in lung function. Treatment with ICS, alone and in combination with a long-acting bronchodilator, reduces dyspnea related to daily activities, whereas withdrawal increases breathing difficulty. Patients with COPD exhibit a significant increase in exercise duration with ICS therapy. The combination of ICS with one or more bronchodilators significantly reduces the exacerbation rate compared with bronchodilator therapy alone. The major serious adverse effect is an increased risk of pneumonia. Conclusion: Randomized controlled trials demonstrate that ICS therapy improves both physiologic and clinical outcomes in patients with COPD. These benefits are enhanced when ICS molecules are combined with one or more long-acting bronchodilators.