Inhaled corticosteroids in COPD: the case against

Chronic obstructive pulmonary disease (COPD), a disease that encompasses emphysema, chronic obstructive bronchitis and small airway obstruction and that is characterised by largely irreversible airflow obstruction, now affects around 10% of the population over the age of 40 yrs 1. The sixth commonest global cause of death in 1990, currently fourth in developed countries, it is expected rise to third place globally by 2020 2. This increase is linked to the trends of its foremost risk factor, tobacco consumption during the twentieth century, and will track the worldwide smoking trends of this century. Besides smoking cessation and pulmonary rehabilitation, the treatment of COPD has previously consisted of bronchodilators early in the disease and oxygen in the late stages. However, because of the presence of inflammation in COPD, short courses of systemic corticosteroids have been used for decades in the treatment of exacerbations, often along with antibiotics. Their side-effects, however, made them unsuitable for the long-term treatment of stable COPD. In the early 1980s, inhaled formulations of corticosteroids were shown to be highly effective for the treatment of asthma and were readily adopted in COPD with no scientific evidence of their benefit in this indication. This transition from asthma to COPD was so natural to prescribers that a Canadian survey conducted in 1994 found that one-third of patients admitted to hospital for COPD were already using inhaled corticosteroids (ICS) 3, despite the fact that no randomised controlled trials had evaluated their effectiveness in COPD. Today, market research studies estimate that the use of these drugs has increased to the point that they are used by >70% of patients with COPD in the USA and Europe, and are currently given as initial therapy to >50% of patients newly diagnosed with COPD, mostly in combination with a long-acting β-agonist (LABA) 4 …