As evidence for inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) treatment has evolved, guidelines have limited the use of ICS-based regimens.

The GOLD guidelines no longer recommend long-acting beta 2 agonist (LABA) + ICS. Patients experiencing major symptoms without further exacerbations should be switched to a long-acting muscarinic antagonist (LAMA) + LABA. To evaluate ICS withdrawal, the real-world EVELUT® study (NCT03954132) followed 463 patients with symptomatic COPD at low exacerbation risk (GOLD B) who were switched, at their physicians’ discretion, from LABA + ICS to LAMA + LABA (n=329) or triple therapy (LAMA + LABA + ICS) (n=134). At 12 weeks, marginally more patients responded to LAMA + LABA than triple therapy, leading the investigators to conclude that the switch to LAMA + LABA improved their symptoms while eliminating ICS-associated risks.

The GOLD guidelines reserve triple therapy for patients with high exacerbation risk and elevated eosinophils, but many patients receive it without clear indication. DACCORD (EUPAS4207), a real-world study, recruited patients who had received triple therapy for at least 6 months (N=1124) and, at their physicians’ discretion, continued it (n=784) or switched to LAMA + LABA (n=340). At 1 year, fewer patients had worsening of COPD with LAMA + LABA versus triple therapy (32.5% vs 55.7%). Also, significantly fewer patients had an exacerbation with LAMA + LABA versus triple therapy (18.5% vs 28.7%; P < 0.001). The investigators concluded that physicians can identify patients to de-escalate from triple therapy to LAMA + LABA with no COPD decline—and potentially better outcomes.

For patients on ICS-containing regimens, when would you consider withdrawing the ICS? If not, why?