Inhaled corticosteroids (ICSs) are a key incorporation to COPD treatment strategies.
Jeffrey D. Dunn, PharmD, MBA: ICSs [inhaled corticosteroids] haven’t shown much evidence in impacting the course of COPD [chronic obstructive pulmonary disease] by itself. But in combination with a LABA [long-acting beta-agonist], there are some data showing that they can reduce exacerbations. We’re going to come back to triplet therapy in a minute. What are the nuances? How do we choose between ICS and LABA vs LABA and LAMA [long-acting muscarinic antagonist]?
Courtney Crim, MD: Good question. One thing that we all recognize is that when it comes to selecting any therapy, you have to do that benefit-risk balance [as you would with] any type of medication. One thing we’re always concerned about with inhaled corticosteroids—particularly in patients with COPD—is the potential for an increased risk of pneumonia. Patients with COPD have an increased risk of pneumonia compared with patients who don’t. We also know that patients with COPD have a further increase if they’re receiving an inhaled corticosteroid. That risk appears to be present more in patients with severe or very severe airflow limitation compared with those who have moderate airflow limitation.
In fact, the SUMMIT trial demonstrated that patients who have moderate airflow limitation don’t have an increased risk of pneumonia compared with patients who received placebo. This risk is definitely real. It’s something we have to take into consideration. Therefore, with patients who have severe airflow limitation and [those who] may have had frequent pneumonias, that’s something we’re very concerned about as it relates to using an inhaled corticosteroid.
Inhaled corticosteroids in combination with a LABA definitely have an impact on improving lung function and decreasing the risk of exacerbations, but that has to be weighed against the potential risk. We know from a number of studies that patients who have low blood eosinophil counts don’t see any added benefit, in terms of reducing exacerbations with an inhaled corticosteroid-containing regimen compared with a bronchodilator.
For example, for patients who have low eosinophils, the impact on reduction in exacerbations appears to be comparable between an inhaled corticosteroid-containing regimen vs a LABA by itself or dual bronchodilators. You see this differential effect in patients who have high eosinophils, but you don’t see it in patients who have low eosinophils. We take into consideration the severity of the airflow limitation and their potential risk for pneumonia in that context, and the other potential adverse effects that patients may develop with inhaled steroids, such as thrush and the potential effects on bone density.
Jeffrey D. Dunn, PharmD, MBA: That’s an important differentiation between COPD and asthma.
Courtney Crim, MD: Correct.
Jeffrey D. Dunn, PharmD, MBA: Is it an overstatement to say that the preferred dual therapy is a LABA-LAMA over an ICS-LABA?
Courtney Crim, MD: In general, yes, perhaps. But it comes back to that individualization of treatment. If a person has moderate airflow limitation, that concern may not be there. But it depends on what’s driving the patient’s symptoms. If dyspnea is a potential issue and not exacerbations, then one would probably be more inclined to go with the bronchodilator route. But even dual bronchodilators have an impact on exacerbations. You tailor the therapy based on the patient’s concern and what’s impacting their disease as it relates to exacerbations, dyspnea, exercise tolerance, and things of that nature.
Transcript edited for clarity.