Inhaled corticosteroids in COPD: pros and cons

Chronic obstructive pulmonary disease (COPD) is a devastating illness characterized by airway and systemic inflammation, progressive airway obstruction and exacerbations. It is a major cause of chronic morbidity and mortality, projected to be the third leading cause of death by the year 2020. Although there is currently no definite cure, COPD is both a preventable and treatable disease. Important changes in our perspective and understanding of the disease have been made that lead to marked improvements in the treatment of COPD, such as the use of long-acting anticholinergics, β2 agonists and inhaled corticosteroids (ICS). Current GOLD guidelines call for the use of ICS in patients with severe and very severe airflow limitation and/or for patients with frequent exacerbations. This population constitutes only around 20% of all COPD patients, however current data show that as much as 70% are prescribed ICS. Although widely used, clinical trials on the efficacy of ICS in COPD have been up to now inconclusive or even contradictory. This has lead to wide confusion and debate regarding their role in the management of COPD. This review summarizes all current knowledge originating from observational studies, randomized clinical trials and expert views regarding ICS therapy in COPD. Arguments in favor and against the use of ICS are presented with respect to airway and systemic inflammation, exacerbation frequency and severity, lung function decline, quality of life, mortality and adverse events.