Inhaled corticosteroids for stable chronic obstructive pulmonary disease

Yang IA, Fong K, Sim EH A, Black PN, Lasserson TJ

Published Online:

July 8, 2009

Steroid preventer medications given by inhaler ('inhaled steroids') help to reduce inflammation in the air passages of people with asthma. However it is uncertain whether these medications are beneficial in people with chronic obstructive pulmonary disease (COPD, i.e. chronic bronchitis or emphysema or both).

We undertook a systematic review of the benefits and safety of inhaled steroids for people with COPD. Our review analysed the effects on breathing capacity, death rates, frequency of flare-ups ('exacerbations'), quality of life and side-effects.

Pooling of the data from the 47 trials with 13,139 people showed that although inhaled steroids resulted in a small improvement in breathing tests initially, there was no long term benefit in the rate of decline in breathing capacity. Death rates were unchanged. Inhaled steroids were beneficial in slowing down the rate of decline in quality of life, and reducing the frequency of exacerbations. Inhaled steroids increased the risk of side effects including thrush (candida) infection in the mouth and hoarseness.

In deciding whether to use this treatment, consumers and health professionals should weigh up the benefits (reduced rate of exacerbations, reduced decline in quality of life) against the side effects (mouth thrush, hoarseness and unknown long-term side effects).

Abstract (click to read)

Background:

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

Objectives:

The objective of the review is to determine the efficacy of regular use of inhaled corticosteroids in patients with stable COPD.

Search strategy:

A pre-defined search strategy was used to search the Cochrane Airways Group specialised register for relevant literature. Searches are current as of October 2006.

Selection criteria:

We selected randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short term beta2-agonists and bronchial hyperresponsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. Data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety were also analysed.

Data collection and analysis:

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

Main results:

Forty-seven primary studies with 13,139 participants met the inclusion criteria. Medium term use of ICS (> two months and up to six months) resulted in a small improvement in FEV1 in some studies. Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients (weighted mean difference (WMD) 5.80 ml/year with ICS over placebo, 95% CI -0.28 to 11.88, 2333 participants). There was no statistically significant effect on mortality in COPD patients (OR 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (WMD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (WMD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.49, 95% CI 1.78 to 3.49, 4380 participants) and hoarseness. The few long term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over 3 years.

Authors' conclusions:

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life), against the known increase in local side effects (oropharyngeal candidiasis and hoarseness). The risk of long term adverse effects is unknown.

This record should be cited as:

Yang IA, Fong K, Sim EH A, Black PN, Lasserson TJ. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD002991. DOI: 10.1002/14651858.CD002991.pub2

Assessed as up to date:

January 6, 2007

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Primary Review Group:

Airways Group

Health topics:

Lungs & airways > Chronic obstructive pulmonary disease (stable) > Corticosteroids (inhaled, oral or intranasal)

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

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