In COPD, do inhaled corticosteroids save lives?

The 2 minute update looks at a study evaluating inhaled steroids for COPD patients. Do they save lives?

Current GOLD guidelines recommend that COPD patients with significant dyspnea be prescribed combination LABA/LAMA for maintenance. Several years ago, multiple studies showed that LABA/LAMA has less risk of pneumonia than LABA/ICS, and the guidelines reflect that. But new data also look at mortality.

This is a huge meta-analysis, including over 103,000 patients in 60 randomized controlled trials. There were various comparisons depending on the trial. Some compared LABA/LAMA with LABA/ICS, some compared triple therapy with dual therapy.

The bottom line is that it appears inhaled corticosteroids save lives. All cause mortality was lower for the patients on inhaled steroids compared to those that were not on steroids. There was lower mortality with LABA/ICS compared to LABA/LAMA, and fewer people who were on triple therapy died compared with those only on LABA/LAMA.

GOLD guidelines recommend LABA/LAMA without inhaled steroids for most COPD patients with moderate or worse dyspnea. They recommend adding inhaled corticosteroids if patients are having exacerbations. But even though adding inhaled steroids increases the risk of pneumonia, it appears to save lives.

We don’t know why inhaled steroids appear to save lives even though they increase the risk of pneumonia. My best guess would be that the patients on the steroids have better exercise capacity – that they simply move more, and we know that physical activity decreases mortality. There is some limited evidence that inhaled steroids do improve exercise capacity in COPD, but it does not appear to be well studied.

Reference: Chen et al. Association of Inhaled Corticosteroids With All-Cause Mortality Risk in Patients With COPD: A Meta-analysis of 60 Randomized Controlled Trials. Chest 2023;163:100