Clinical Question

Does inhaled corticosteroid (ICS) monotherapy improve exacerbation outcomes in patients with stable chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

ICS monotherapy decreases the likelihood of exacerbations in patients with stable COPD compared with placebo.¹ (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

COPD is a pulmonary inflammatory condition characterized by airway obstruction.² COPD affects more than 15 million people in the United States, causing more than 150,000 deaths per year.³ Primary care physicians need to recognize COPD and provide treatment to reduce exacerbations because of the related morbidity and socioeconomic burden. ICS monotherapy can benefit patients with COPD; however, its role is uncertain because recommendations have favored using ICS therapy in combination with long-acting bronchodilators.

The authors of this Cochrane review assessed studies published up to October 2022 that compared ICS monotherapy (commonly budesonide) vs. placebo in patients with stable COPD.¹ Primary outcomes included COPD exacerbations, quality of life using the validated St. George’s Respiratory Questionnaire, all-cause mortality, lung function (e.g., forced expiratory volume in one second [FEV₁]), use of rescue bronchodilators, exercise capacity, pneumonia, and thrush. Outcomes were measured by rates of hospitalization and oral corticosteroid and antibiotic use. This review included 36 randomized, double-blind, placebo-controlled trials with 23,139 participants. Most studies were conducted in the United States, Canada, Europe, and Africa in multicenter/hospital outpatient clinics. Outcomes were consistent among studies. The duration of follow-up was three to six months (17 studies) or more than six months to three years (19 studies). The standardization for using long-acting muscarinic antagonists/long-acting beta₂ agonists or other treatments could not be reported.