In asthma, there is general agreement that the benefits of ICS clearly outweigh the side effects and possible risks associated with long-term use . As this may not be the case in COPD, it is worthwhile to consider both side effects and the potential risks associated with including ICS in the armamentarium of drugs for COPD.
Local side effects such as oral candidiasis and hoarseness are quite frequent, and systemic side effects are perhaps not as infrequent as is often believed in asthma. In EUROSCOP, an excess 6% developed bruises on the forearms > 5 cm in diameter at least once during the trial , and although it was firmly stated that no other systemic side effects were seen, bruises are markers of systemic effects and it is likely that the study was underpowered to detect more deleterious effects. In a subsample in EUROSCOP, no effects of treatment with ICS were seen on bone mineral density, but as long-term treatment will often be offered to patients with an unfavourable osteoporosis profile (smoking, minimal physical activity and inappropriate nutrition), this potential problem has not been solved. In fact, in LHSII an increased loss of bone mineral density was found in the femoral neck, but not in the lumbar spine, and this should indicate a need for caution. Wisniewski et al.  showed an association between the cumulative dose of ICS and loss of bone density, and two other studies have also increased awareness of the risk of cataracts developing in elderly patients taking ICS [31,32].
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