How then should inhaled corticosteroids be used in COPD

First of all, it seems clear that not all COPD patients should be given ICS. As illustrated in Fig. 10.3, there is no evidence of any disease-modifying effect; that is, no effect on FEV1 decline has been observed. From the studies reported, patients with mild COPD have no benefit whatsoever from treatment with ICS.

Patients with moderate COPD in general should in my opinion not automatically be put on inhaled steroids, although this seems to be the current clinical practice in many countries. There seems to be little evidence that inhaled corticosteroids are helpful in managing patients with an FEV1 above 1.5 L.

In my opinion, only patients with marked airflow limitation who experience frequent exacerbations and who also have a low health status definitely benefit from treatment. 'Marked airflow limitation' can be defined from ISOLDE as FEV1 < 1.25L, or < 40% predicted. These patients by definition have severe COPD. There are, however, a few patients with moderate disease who fit the description of having frequent exacerbations and low health status, and these patients should probably be considered for treatment as well. It is not clear whether patients with severe disease but infrequent exacerbations will benefit from ICS, but it is most likely that they will not.

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