Weighing ICS Benefits vs Long-Term Systemic Side Effects in COPD: Sara Assaf, MD

There are significant long-term systemic risks of using inhaled corticosteroids (ICS) in the management of chronic obstructive pulmonary disease (COPD) beyond pneumonia, including osteoporosis, candidiasis, and effects on blood sugar, explained Sara Assaf, MD, assistant professor of pulmonary and critical care at the University of New Mexico School of Medicine.

Assaf also outlined the clinical decision-making process for de-escalation—moving stable patients from triple therapy with ICS to dual therapy without ICS.

This transcript has been edited for clarity; captions were auto-generated.

Transcript

Beyond pneumonia, what are the most significant long-term systemic risks associated with ICS use in COPD? How can a general practitioner screen for them or implement mitigation strategies?

I think we definitely worry about increased pneumonia risk, sometimes in COPD patients who might have bronchiectasis. We might worry also about nontuberculous mycobacteria with the inhaled steroids and then the usual side effects like oropharyngeal candidiasis, eye-related effects, and bone-related effects with osteoporosis or changes in the sugar levels.

Depending on the patients, I think assessing their risk factors, bone densitometry, maybe, or if they're diabetic, checking their sugar levels more often, making sure they have good techniques with using their triple inhalers, whether they're the powder ones or the pressurized ones for the 2 options. Usually making this kind of baseline screening to assess the risks to benefits from adding inhaled corticosteroids to any dual bronchodilator or monotherapy that they're on.

For patients on triple therapy who are stable, would you consider de-escalating treatment to remove the ICS and move them to a dual therapy? What would go into making that decision?

There are some, maybe ERS [European Respiratory Society] guidelines, that can help with that perspective. But in general, in clinical practice, if they've been doing okay with no exacerbations over the past year or so, and their blood eosinophilic count is less than 100 [cells/µL], and then weighing as we talk the risk to benefit from inhaled corticosteroid, you might consider withdrawal of inhaled corticosteroid. A lot [of clinicians] might just taper it down first and then withdraw it, rather than right away totally withdrawing the inhaled steroid. It will depend on their clinical response, as well as some biomarkers like blood eosinophilic count that could be used to better guide that decision.