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1yr
Maintenance therapy for COPD: what happens when you withdraw ICS?

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?

  • 1yr
    ICS withdrawal should be considered in patients who have severe symptoms but are NOT having frequent exacerbations and do NOT have high eosinophils.
  • 1yr
    good to see evidence that deescalation to laba/lama is reasonable if patients experience stabilization on 3x therapy.
  • 1yr
    the data is in if patient have relatively no exderbations with there copd an low esinophils,ics is no longer needed,they should be switch to a LABA PLUS LAMA
  • 1yr
    I would withdrawal ICS if they've had recurrent pneumonia or oral side effects clearly due to the ICS. Agree with others many are started inappropriately on triple therapy in the first place and can get by with LABA LAMA alone and would consider stopping ICS there as well. If they clearly have asthmatic component to their COPD would consider staying on the ICS
  • 1yr
    an individual with no recent cop exacerbations. Clearly no emergency room visits or hospitalizations. Additionally likely they are no longer smoking and their COPD is relatively stable. Additionally consider withdrawing patients with any side effects such as thrush or even dysphonia or history of diabetes. Finally a low eosinophil count, or at least not as high one.
  • 1yr
    the majority of the scenarios would be patients started on the ICS inappropriately prior to being under my care. many patients with COPD are sent on ICS/LABA combination, and addressing that along with other basics of care are all too common. Otherwise would withdraw for those who are not exacerbating, no eosinophils, etc
  • 1yr
    Interesting data… I have started usingLAMA
    LABA a lot more now and reserve the ICS for more severe cases. It can be a bit difficult at times to withdraw ICS from patients who are stable and on it for few years but would consider doing it.
  • 1yr
    Wow! That is such interesting and reassuring real world data - basically less is more and win-and-win for everyone.
  • 1yr
    QUIT SMOKING ;FEW EXACERBATION,ALSO LOWER EOSINOPHILS WITH FEWER OUTDOOR ALLERIES ;LAMA AND LABA WILL WORK WITHOUT ICS
  • 1yr
    I have found alot of patient can "step-down" from ICS. Especially if other factors like smoking, allergies are modified. So yes I recommend trial of inhalers without ICS
  • 1yr
    I use triple therapy to manage COPD patients but tend to encounter insurance coverage issues. I typically do not remove ICS from patients already using them - but this data sounds favorable for these changes. Change to LAMA + LABA without ICS.
  • 1yr
    I commonly withdrawal ICS in patients receiving "triple therapy" if they have blood eos less than 300 cells/uL and less than 2 exacerbations in last year.
    There are clearly some patients with COPD who benefit from ICS but many who do not.
  • 2yr
    I often use triple therapy to manage COPD patients but tend to encounter insurance coverage issues. I do not remove ICS from patients already using them. I found removal leads to exacerbations and complaints from patients especially ones that have needed oral steroids for past exacerbations.
  • 2yr
    ICS is defintely an agent that should be incorporated when pt is having the exacerbation or progressive symptoms of COPD as with the protocol with systemic steroid use that it should be tapered off or dose minimized once the disease prcoess has been stablized and in remission the same applies to the ICS and COPD management should be reviewed and the need for ongoing ICS should be justified and no wonder GOLD guidelines are following the same paradigm and makes lot of clinical sense porgressive COPD usally persistent smoking is the factor and efforts need to be done to help pt quit smoking also need be mindful of the alpha antitrypsin deficiecny to manage it appropriately
  • 2yr
    Basically less is more when it comes to COPD patients without a history of frequent exacerbations Yet those patients may have worse lung function without ICS. Moving forward with de-escalation of ICS, it will require close monitoring from a physician’s stand point and an understanding of benefits and harms from a patient’s view.
  • 2yr
    Certainly most chronic obstuctive pulmonary disease patients do not require inhaled corticosteroid therapy in their medication cabinet unless they have significant eosinophils in the peripheral blood or if they were to have repeated exacerbation of chronic obstuctive pulmonary disease requiring hospitalization
    Majority of them respond very well to combination of long-acting muscarinic antagonist and long-acting beta 2 adrenergic agonist inhaler and with fewer exacerbations.
  • 2yr
    most high risk copd are the ones that still smoke had multiple exacerbations with high eosinophils, i will still use a triple who quit smoking and no exacerbations and low eosinophils discontinue ICS and use a double

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