Inhaled Corticosteroid Use in Asthma and COPD

Introduction to ICS Use

The American Thoracic Society and European Respiratory Society recommend ICS as the preferred long-term controller therapy for asthma in all age groups, with benefits on symptoms, lung function, quality of life, exacerbations, and mortality 1
For COPD, ICS should only be used in combination with long-acting bronchodilators and reserved for specific high-risk patients with frequent exacerbations, elevated eosinophils, or asthma-COPD overlap 2, 3

The Global Initiative for Asthma recommends ICS as the preferred long-term controller therapy for asthma, with no single agent demonstrably superior for mortality, morbidity, or quality of life 1, 2
ICS selection should be based on available delivery devices and patient ability to use them correctly, with most therapeutic benefit occurring at low-to-medium doses 1

The Global Initiative for Chronic Obstructive Lung Disease recommends against ICS monotherapy in COPD, as it increases adverse events without benefit in symptoms, exercise tolerance, or health status 2, 3
ICS must only be used in combination with long-acting bronchodilators (LABA and/or LAMA) in COPD patients with specific criteria, including blood eosinophil count ≥300 cells/µL, history of ≥2 moderate exacerbations per year, or FEV₁ <50% predicted 2, 4, 5, 6
The American College of Chest Physicians recommends LABA/ICS combinations as the standard formulations when ICS is indicated for COPD 4
Triple therapy (LAMA/LABA/ICS) is recommended for GOLD Group D patients with high symptom burden and frequent/severe exacerbations despite dual bronchodilator therapy 4, 7, 2, 8

ICS increases pneumonia risk in COPD, particularly in patients with severe/very severe disease, with a number needed to harm of 33 patients for 1 year to cause one pneumonia 2, 4, 5, 6
The European Respiratory Society recommends monitoring patients on ICS for signs and symptoms of pneumonia, as well as other adverse effects such as oral candidiasis, adrenal suppression, and decreased bone mineral density 2, 5, 6

The American Thoracic Society recommends against using ICS in COPD patients with low exacerbation risk (Groups A and B), instead using short- or long-acting bronchodilator monotherapy or LAMA/LABA dual therapy 4, 2, 3
For high exacerbation risk (Groups C and D), ICS should only be added to LAMA/LABA baseline therapy if specific criteria are met, including eosinophils ≥300 cells/µL, ≥2 exacerbations/year, or FEV₁ <50% predicted 5, 6, 2