Withdrawal of ICS treatment in primary care: A practical guide

Abstract

Inhaled corticosteroids (ICS) are frequently inappropriately prescribed for patients with COPD resulting in up to 70% of patients in current practice receiving them. ICS (prescribed as a combination inhaler with a long-acting beta2-agonist (LABA)) are primarily indicated for patients with an FEV1<50% predicted and a history of frequent exacerbations. There is a consensus that they provide no benefit for patients with preserved lung function and no history of exacerbations. Safety concerns, particularly with regard to pneumonia, osteoporosis, bruising, adrenal suppression and diabetes have been reported in ICS users. Withdrawal of ICS in these patients may therefore promote cost-effective prescribing, and reduce the risk of adverse effects. Nevertheless, in the absence of recognised national guidelines, removing a longstanding therapy from patients with COPD can be challenging. Concerns and barriers reported by clinicians include the risk that patients may subsequently exacerbate or experience a worsening of symptoms, the risk of inadvertently removing ICS from patients with a diagnosis of asthma, and the risks of adrenal insufficiency. Recent randomised controlled trials clearly demonstrate it is possible to remove ICS in a subgroup of patients with COPD and replace with bronchodilator therapies, and that such withdrawal does not result in clinically important increases in exacerbations or worsening of symptoms. In this article, we provide practical advice about when and how to withdraw ICS in patients with COPD.