PAD Refills
Last updated on February 13, 2025February 2025
What do COPD guidelines recommend regarding inhaled corticosteriod (ICS) discontinuation in people with COPD?
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Conclusion: After excluding a diagnosis of asthma, COPD guidelines recognize potential for ICS deprescribing in some patients who are at low risk for exacerbations or are experiencing ICS-related adverse events. COPD patients with blood eosinophil counts ≥ 0.3 x 109/L are identified as a subgroup at increased risk of exacerbations if ICS therapy is discontinued.
The BC Provincial Academic Detailing (PAD) service’s topic COPD: Triple therapy and device choice looks at the evidence for prescribing and deprescribing decisions for triple therapy (ICS+LAMA+LABA) and compares the features of inhaler device types.1 Visit www.bcpad.ca to book a session with an academic detailing pharmacist in your area.
COPD guidelines define patients as low risk of exacerbations if they have experienced ≤ 1 moderate exacerbation in the past year and high risk if they have experienced ≥ 2 moderate or ≥ 1 severe exacerbation in the past year.2-4 A moderate exacerbation is managed with outpatient antibiotics +/- oral corticosteroid, while a severe exacerbation is one resulting in hospitalization or an emergency room visit.2-4
Evidence that underlies recommendations about ICS discontinuation include: (a) the recognized potential for ICS-related adverse events including pneumonia, (b) ICS deprescribing trials which provide only limited information on patient-important outcomes such as exacerbations, and (c) poorer outcomes in high exacerbation risk patients who had their ICS treatment abruptly discontinued in recent trials.5-12 The table below outlines where three recent guidelines identify a potential role for ICS deprescribing and where they recommend/suggest ICS continuation.2-4
| ICS deprescribing versus ICS continuation in people with COPD who are currently receiving an ICS | ||||
|---|---|---|---|---|
| Clinical scenarios after excluding a diagnosis of asthma |
GOLD 20252 Global Initiative for Chronic Obstructive Lung Disease Report |
CTS 20233 Canadian Thoracic Society Pharmacotherapy Guideline |
ERS 20204 European Respiratory Society Guideline on ICS Withdrawal in COPD |
|
| ICS was initiated without a compelling indication | Potential for ICS deprescribing* | Potential for ICS deprescribing* | Potential for ICS deprescribing (weak recommendation) | |
| Significant ICS-related adverse events have emerged or COPD symptoms have not improved after adding an ICS | Potential for ICS deprescribing* | Potential for ICS deprescribing* | Factors to consider when reviewing ICS therapy* | |
| Higher blood eosinophil counts (e.g., ≥ 0.3 x 109/L) | Exacerbation risk is increased if ICS is discontinued* | Exacerbation risk is increased if ICS is discontinued* | Recommend against ICS deprescribing (strong recommendation) | |
| High exacerbation risk or symptom burden/health status impairment remains moderate-high while on ICS+LAMA+LABA | Recommend against ICS deprescribing (weak recommendation) | |||
| * Guideline statement or comment without a systematically-developed recommendation. If the recommendation was formally graded (weak/conditional, strong), the strength of recommendation has been included. |
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If discontinuing the ICS component from ICS+LABA or ICS+LAMA+LABA combinations, GOLD 2025 and CTS 2023 recommend a switch to LAMA+LABA in most cases.2,3
1BC PAD Service COPD: Triple therapy and device choice; 2GOLD 2025 Report; 3CTS CHEST 2023 (PMID:37690008); 4ERS Eur Resp J 2020 (PMID:32366483); 5COSMIC Thorax 2005 (PMID:15923248); 6INSTEAD Eur Respir J 2014 (PMID:25359348); 7WISDOM N Engl J Med 2014 (PMID:25196117); 8SUNSET Am J Respir Crit Care Med 2018 (PMID:29779416); 9IMPACT N Engl J Med 2018 (PMID:29668352); 10ETHOS N Engl J Med 2020 (PMID:32579807); 11US FDA 2020 Trelegy Ellipta Review; 12US FDA 2020 Approval Package Breztri Aerosphere
2025
2024
- December: Denosumab for osteoporosis: Two important updates (PDF, 263KB)
- November: What evidence exists for using lisdexamfetamine (Vyvanse®) in binge eating disorder in adults and how does this relate to weight loss? (PDF, 239KB)
- October: Which B.C. residents with mild-moderate COVID-19 are recommended to be treated with Paxlovid™ (nirmatrelvir/ritonavir)? (PDF, 258KB)
- September: Which factors should be considered when prescribing a bisphosphonate for frail or older adults living in long-term care? (PDF, 248KB)
- June: Why does a recent guideline recommend against the use of DPP4 inhibitors such as linagliptin (Trajenta®) in people with type 2 diabetes? (PDF, 241KB)
- May: What is the evidence for bupropion for ADHD in adults? (PDF, 239KB)
- April: COPD inhaled medication table update (PDF, 308KB) – updated in February 2025
- March: What is the role for orlistat (Xenical®) given the emergence of newer medications for weight loss in adults? (PDF, 270KB)
- February: What is romosozumab (Evenity™) and what is the evidence for it compared to bisphosphonates? (PDF, 241KB)
- January: What is the rationale for potentially holding GLP1 agonists, such as semaglutide (Ozempic®), preoperatively? (PDF, 253KB)
2023
- December: Is 300 mg per day the target dose of bupropion (Wellbutrin®) for major depressive disorder? (PDF, 293KB)
- November: When should serum calcium be checked in people initiating or taking denosumab (Prolia®) for fracture risk reduction? (PDF, 275KB)
- October: Should adults take 2000 IU of vitamin D daily to prevent fractures? (PDF, 273KB)
- September: How achievable is an HbA1c < 7% in people with type 2 diabetes when a second medication is added to metformin? (PDF, 304KB)
- June: Vyvanse and Dexadrine (PDF, 270KB)
- May: Switching to chlorthalidone compared to continuing hydrochlorothiazide: A new trial (PDF, 277KB)
- April: Zopiclone: dose, next-day impairment, tablet strengths (PDF, 261KB)
- February: Medications marketed in Canada for T2DM (PDF, 271KB)
- January: Melatonin supplementation in children with ADHD
2022
- December: SGLT2 inhibitors in patients with reduced kidney function (PDF, 285KB)
- November: Special Authority eForms (PDF, 321KB)
- October: Lipid-lowering medications (PDF, 303 KB)
- September: Increasing insulin glargine in people with type 2 diabetes (PDF, 253KB)
- June: The Why, Who, What, Where and How of nirmatrelvir/ritonavir (Paxlovid™) (PDF, 255KB)
- May: Osteoporosis Medication Table Update (PDF, 241KB)
- April: Can thiazides be continued in patients with chronic kidney disease when eGFR progresses below 30 mL/min/1.73m2? (PDF, 260KB)
- February: What do I need to know about sulfonylurea medications’ glucose lowering effect, dose and cost? (PDF, 247KB)
- January: What do I need to know about metformin’s glucose lowering effect, formulations, dose and cost? (PDF, 262KB)
2021
- December: Is quetiapine a safer alternative to zopiclone for insomnia? (PDF, 246KB)
- November: For people with type 2 diabetes, how does the oral daily formulation of semaglutide (Rybelsus®) compare with the subcutaneous weekly formulation (Ozempic®)? (PDF, 248KB)
- October: How does eszopiclone (Lunesta®) differ from zopiclone? (PDF, 242KB)
- September: Does vortioxetine (Trintellix®) improve cognitive functioning in people with major depressive disorder? (PDF, 242KB)
- June: What is lemborexant (Dayvigo) and how does it differ from other hypnotics for insomnia, such as zopiclone? (PDF, 247KB)
- May: Hypertension Medication Table Update (PDF, 251KB)
- April: Why and how should adverse drug reactions be reported? (PDF, 257KB)
- March: Is there a relationship between mirtazapine (Remeron®) dose and sedation? (PDF, 190.5KB)
- February: What is a prescribing cascade? The case of calcium channel blocker induced peripheral edema and loop diuretics (PDF, 188KB)
- January: Is venlafaxine (an SNRI antidepressant) more efficacious than SSRI antidepressants for generalized anxiety disorder? (PDF, 166KB)
2020
- December: Asthma Inhaled Medication Table Update (PDF, 216KB)
- November: COPD inhaled medication table update (PDF, 307KB) – updated in November 2024
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