title: A re-evaluation of the role of inhaled corticosteroids in the management of patients with chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Inhaled corticosteroids (ICS) (in fixed combinations with long-acting β2-agonists [LABAs]) are frequently prescribed for patients with chronic obstructive pulmonary disease (COPD), outside their labeled indications and recommended treatment strategies and guidelines, despite having the potential to cause significant side effects.
  
  
  METHODS
  Although the existence of asthma in patients with asthma-COPD overlap syndrome (ACOS) clearly supports the use of anti-inflammatory treatment (typically an ICS/LABA combination, as ICS monotherapy is usually not indicated for COPD), the current level of ICS/LABA use is not consistent with the prevalence of ACOS in the COPD population. Data have recently become available showing the comparative efficacy of fixed bronchodilator combinations (long-acting muscarinic antagonist [LAMA]/LABA with ICS/LABA combinations). Additionally, new information has emerged on ICS withdrawal without increased risk of exacerbations, under cover of effective bronchodilation.
  
  
  CONCLUSIONS
  For patients with COPD who do not have ACOS, a LAMA/LABA combination may be an appropriate starting therapy, apart from those with mild disease who can be managed with a single long-acting bronchodilator. Patients who remain symptomatic or present with exacerbations despite effectively delivered LAMA/LABA treatment may require additional drug therapy, such as ICS or phosphodiesterase-4 inhibitors. When prescribing an ICS/LABA, the risk:benefit ratio should be considered in individual patients.
authors.affiliation: University of Toronto, Department of Family and Community Medicine , 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7 , Canada +1 416 652 9336 ; +1 416 652 0218 ; tonydurzo@sympatico.ca.
authors.forename: Anthony
authors.initials: A
authors.lastname: D'Urzo
authors.forename: James F
authors.initials: JF
authors.lastname: Donohue
authors.forename: Peter
authors.initials: P
authors.lastname: Kardos
authors.forename: Marc
authors.initials: M
authors.lastname: Miravitlles
authors.forename: David
authors.initials: D
authors.lastname: Price
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D058666:Adrenergic beta-2 Receptor Agonists / Q000627:therapeutic use; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D001249:Asthma / Q000150:complications / Q000188:drug therapy; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D019468:Disease Management; D004359:Drug Therapy, Combination; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D018727:Muscarinic Antagonists / Q000627:therapeutic use; D058988:Phosphodiesterase 4 Inhibitors / Q000627:therapeutic use; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000188:drug therapy*; D013577:Syndrome
chemical_list: D000305:Adrenal Cortex Hormones; D058666:Adrenergic beta-2 Receptor Agonists; D000893:Anti-Inflammatory Agents; D001993:Bronchodilator Agents; D005938:Glucocorticoids; D018727:Muscarinic Antagonists; D058988:Phosphodiesterase 4 Inhibitors
keywords: chronic obstructive pulmonary disease; inhaled corticosteroid; long-acting muscarinic antagonist; long-acting β2-agonist