Oral
corticosteroids are powerful relatively nonspecific
antiinflammatory agents with a range of well-characterized side effects. There is good evidence to show that they accelerate the rate of resolution of exacerbations of
COPD and relapse is less likely if patients receive these drugs. Maintenance
therapy with oral preparations is associated with worse mortality and skeletal muscle
myopathy is a particular problem.
Corticosteroids have little effect on biopsy proven
inflammation or its surrogates in
COPD and did not change the rate of decline of FEV (1) over a range of spirometric disease severity in a number of trials each lasting 3 years. However, meta-analysis of the data suggests that a small effect (up to 10 ml /year) might be present. There is more consistent evidence for an effect on postbronchodilator FEV (1) with both
fluticasone propionate and
budesonide. In patients with a postbronchodilator FEV (1) < 50% predicted where self-reported exacerbations become more common, inhaled
corticosteroids can reduce the number of attacks. This effect is the major factor accounting for the reduction in deterioration in health status seen in patients who receive inhaled
corticosteroids. Inhaled
corticosteroids are much safer than oral
therapy, although they do have a predictably higher incidence of
candidiasis and
hoarseness of the voice. Skin bruising is seen in patients with better lung function who use these drugs.
Triamcinolone use is associated with reduction in bone density but this was not seen with
budesonide. Combining an inhaled
corticosteroid and a long-acting beta-agonist in the same
inhaler increases the efficacy of the latte
drug in
COPD patients, with a significantly larger improvement in FEV (1), a larger reduction in reported
breathlessness, and a reduction in exacerbation numbers in those with severe disease where beta-agonists appear to be less effective. Inhaled
corticosteroids are not suitable for monotherapy in
COPD but can be helpfully combined with an inhaled
bronchodilator in patients with symptomatic disease.