Inhaled Corticosteroids: Effective in COPD?

Q:Is there a role for inhaled corticosteroids in chronic obstructivepulmonary disease (COPD)?A:We do not yet have a well-tolerated pharmacologic agent that affects thebasic inflammatory and other destructive processes that cause COPD.Thus far, smoking cessation is the only measure known to modify the diseaseprocess: it slows the rate of decline of forced expiratory volume in 1 second(FEV₁). The rate of decline is a powerful prognostic indicator in COPD.Inhaled corticosteroids are a cornerstone of the maintenance managementof all but the mildest intermittent forms of asthma. But we now know that the inflammatorymediators of COPD differ significantly from those involved in asthma.¹ At least 5 studies have failed to show that budesonide, fluticasone, or triamcinoloneslowed the rate of decline in FEV₁ in patients with COPD.^2-6 However,2 of those studies showed a reduction in bronchial hyperactivity and a decreasein symptoms that resulted in fewer exacerbations and fewer hospitalizations forCOPD.^5,6In 1 of those studies, triamcinolone was associated with a measurable lossof bone density.⁶ This effect is of particular concern when inhaled corticosteroidsare used for prolonged periods.Another study suggested improved survival associated with inhaled corticosteroidsin elderly patients with advanced COPD.⁷ However, this was an observationalstudy; a prospective, randomized, controlled clinical trial is warranted.The take-home message appears to be that inhaled corticosteroids relievesymptoms and are probably most valuable in older patients at more severestages of COPD. Warn patients about the possibility of osteoporosis and othersystemic effects, such as acceleration of cataract development and insulin resistance.Costs and adverse effects also need to be considered when corticosteroidsare prescribed.It is hoped that ongoing research will lead to the discovery of nonsteroidaldrugs that can alter the basic pathogenesis and pathophysiology of COPD, particularlyin the mild to moderate stages.

References:

REFERENCES:

1.

Barnes PJ. Chronic obstructive pulmonary disease.

N Engl J Med

. 2000;343:269-280.

2.

Paggiaro PL, Dahle R, Bakran I, et al, for the International COPD Study Group. Multicentre randomisedplacebo-controlled trial of inhaled fluticasone propionate in patients with chronic obstructive pulmonary disease.

Lancet

. 1998;351:773-780.

3.

Vestbo J, Sorensen T, Lange P, et al. Long-term effect of inhaled budesonide in mild and moderate chronicobstructive pulmonary disease: a randomised controlled trial.

Lancet

. 1999;353:1819-1823.

4.

Pauwels RA, Lofdahl CG, Laitinen LA, et al, for the European Respiratory Society Study on Chronic ObstructivePulmonary Disease. Long-term treatment with inhaled budesonide in persons with mild chronicobstructive pulmonary disease who continue smoking.

N Engl J Med

. 1999;340:1948-1953.

5.

Burge PS, Calverley PM, Jones PW, et al, for the ISOLDE trial. Randomised, double blind, placebo controlledstudy of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonarydisease.

BMJ

. 2000;320:1297-1303.

6.

The Lung Health Study Research Group. Effect of inhaled triamcinolone on the decline in pulmonaryfunction in chronic obstructive lung disease.

N Engl J Med

. 2000;343:1902-1909.

7.

Sin DD, Tu JV. Inhaled corticosteroids and the risk of mortality and readmission in elderly patients withchronic obstructive pulmonary disease.

Am J Respir Crit Care Med

. 2001;165:580-584.