Bronchodilators (long-acting beta agonists and anticholinergics) form foundation therapy for COPD, and have been found not only to provide symptomatic relief, but also reduce the frequency of acute exacerbations. When COPD becomes severe, and especially in patients with frequent exacerbations, it is appropriate to also include inhaled corticosteroids. Often, COPD patients are treated with triple therapy: a long-acting beta agonist (LABA), long-acting anticholinergic agent (LACA), and inhaled corticosteroid (ICS). Once stable, however, some have questioned whether continuation of the ICS exerts meaningful benefit.
To address this issue, Magnussen et al performed a double-blind trial among severe COPD patients (n = 2,485). Patients on triple therapy (LABA + LACA + ICS) were randomized to either continue on that regimen or receive LABA + LACA + placebo ICS. The primary outcome of the study was time to first moderate or severe COPD exacerbation.
ICS withdrawal did not lead to any significant change in time to COPD exacerbation, dyspnea, or other measures of health status at one year. Although there were measurable differences between ICS-maintained vs ICS-withdrawn groups in FEV1 at study end (slightly improved FEV1 in the former), the magnitude of difference was of questionable clinical significance. These data would suggest that consideration of ICS discontinuation in patients on triple therapy may generally be accomplished without worsening likelihood of exacerbations.
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