title: Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice.
abstract: Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.
authors.affiliation: Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada ; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alan G
authors.initials: AG
authors.lastname: Kaplan
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000009:adverse effects; D000465:Algorithms; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001993:Bronchodilator Agents / Q000008:administration & dosage* / Q000009:adverse effects; D019091:Critical Pathways; D018450:Disease Progression; D004359:Drug Therapy, Combination; D019983:Guideline Adherence; D006801:Humans; D057970:Inappropriate Prescribing; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D000069342:Medical Overuse; D018579:Patient Selection; D010641:Phenotype; D017410:Practice Guidelines as Topic; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D020127:Recovery of Function; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D000893:Anti-Inflammatory Agents; D001993:Bronchodilator Agents
keywords: algorithm; bronchodilation; chronic obstructive pulmonary disease; clinical practice; inhaled corticosteroid; withdrawal