Practice Therapeutics

Inhaled corticosteroids for chronic obstructive pulmonary disease

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6843 (Published 25 October 2012) Cite this as: BMJ 2012;345:e6843
  1. Hye Yun Park, visiting research fellow,
  2. S F Paul Man, professor of medicine,
  3. Don D Sin, professor of medicine
  1. 1Institute of Heart and Lung Health (UBC James Hogg Research Center), St Paul’s Hospital, Vancouver, BC, Canada
  2. 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Seoul, South Korea
  3. 3Department of Medicine (Respiratory Division), University of British Columbia, Vancouver, BC, Canada
  1. Correspondence to: D D Sin, St Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6 don.sin{at}hli.ubc.ca

A 65 year old female former smoker presents to your practice with gradually worsening shortness of breath while walking up a flight of stairs and a daily cough, productive of small amounts of white phlegm. She has a smoking history of 20 cigarettes a day for 20 years and chronic obstructive pulmonary disease (COPD). Her breathlessness had gradually worsened since an influenza-like illness six months ago, which was treated with a two week course of oral prednisolone and antibiotics. Since the illness she has used inhaled tiotropium 18 µg once daily and inhaled salbutamol as needed. Spirometry at the general practice shows a forced expiratory volume in one second (FEV1) of 63% predicted and a ratio of FEV1 to forced vital capacity of 0.65 after use of a bronchodilator. These values have not changed significantly over the previous year. As she is still symptomatic, her general practitioner recommends stopping tiotropium and starting a combination inhaler of a corticosteroid and a long acting β2 agonist.

What are inhaled corticosteroids?

Inhaled corticosteroids are glucocorticoids that bind to the glucocorticoid receptors in the airways and cause a reduction in lung inflammation.1 They are taken via metered dose inhalers or dry powder inhalers. The most commonly used inhaled corticosteroids in COPD are fluticasone propionate, budesonide, and beclometasone dipropionate (table 1).

View this table:
Table 1

Combinations of inhaled corticosteroids plus long acting β2 agonists for chronic obstructive pulmonary disease (COPD). Monotherapy with inhaled corticosteroids is not approved for the treatment of COPD

How well do inhaled corticosteroids work in COPD?

The role of inhaled corticosteroids in COPD is controversial. However, on the basis of current evidence, using them as monotherapy cannot be recommended for most patients with this condition. The effect of such monotherapy in relieving dyspnoea and improving lung function is modest and weaker than that of long acting bronchodilators.2 Inhaled corticosteroids also …

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