TABLE 1

Recommendations for inhaled corticosteroid use or withdrawal in chronic obstructive pulmonary disease according to several international and national guidelines

GuidelineInitiationEscalationDe-escalation#
GOLD 2021 [1]In most cases (GOLD A–C and most D): LAMA or LABA or LAMA/LABA.LAMA or LABA to ICS/LABA: eosinophils ≥300·µL−1 or and two moderate exacerbations/one hospitalisation.Pneumonia, inappropriate initial indication and/or lack of response to ICS.
De-escalation: close monitoring if eosinophils ≥300·µL−1.
ICS/LABA option: if dyspnoea and exacerbations (GOLD D) and eosinophil counts ≥300·µL−1.LAMA/LABA to triple therapy: exacerbations and eosinophils ≥100·µL−1.
ATS 2020 [32]If dyspnoea: LAMA/LABA.LAMA/LABA to triple therapy: ≥1 exacerbation in the past year.No exacerbations in the past year.
ICS/LABA option: ≥1 exacerbation in the past year, if eosinophil counts ≥150·µL−1 (2%).
ERS 2020 [33]No specific guidelines regarding ICS.Blood eosinophils <300·μL−1 and no frequent exacerbations.
SPLF 2021 [34]Preferred option: LAMA or LABA.LAMA or LABA to ICS/LABA: exacerbations and no dyspnoea (mMRC <2), eosinophil count (>300·µL−1) to be considered as a secondary criterium.ICS-associated adverse events, eosinophils <300·µL−1 or no exacerbation in the past year.
ICS/LABA: not recommended.LAMA/LABA to triple therapy: dyspnoea and/or ≥1 severe or ≥2 moderate exacerbations in the past year.
NICE 2019 [35]Preferred option: LAMA/LABA.LAMA/LABA to triple therapy: daily symptoms that adversely impact quality of life or one severe or two moderate exacerbations within a year.Symptoms not improved after 3 months on triple therapy.
ICS/LABA: if asthmatic features or features suggesting steroid responsiveness+.
CTSCPG 2019 [36]LAMA or LABA if low risk of AECOPD§.LAMA or LABA to ICS/LABA: if concomitant asthma.No improvement in dyspnoea, exercise tolerance or health status, and no history of frequent and/or severe AECOPD improved by triple therapy.
ICS/LABA: ≥1 exacerbation in the past year and eosinophils ≥300·µL−1.LAMA/LABA to triple therapy: persistent.
dyspnoea and poor health status in the last year.

#De-escalation: triple therapy (LAMA/LABA/ICS) to LAMA/LABA. Preferred option in patients with exacerbations. +Higher blood eosinophil count, substantial variation in forced expiratory volume in 1 s (FEV1) over time (≥400 mL) or substantial diurnal variation in peak expiratory flow (≥20%). §Low versus high risks of AECOPD: ≥1 moderate AECOPD versus ≥2 moderate AECOPD or ≥1 severe AECOPD (hospitalisation) in the last year.

AOCOPD: acute exacerbation of chronic obstructive pulmonary disease; ATS: American Thoracic Society; COPD: chronic obstructive pulmonary disease; CSI: corticosteroid inhaler; CTSCPG: Canadian Thoracic Society clinical practice guideline; ERS: European Respiratory Society; GOLD: Global Initiative for Chronic Obstructive Lung Disease; ICS: inhaled corticosteroid; LAMA: long-acting bronchodilators, including muscarinic antagonists; LABA: long-acting beta2 agonists; mMRC: modified Medical Research Council; NICE: National Institute for Heath and Care Excellence; SPLF: French Respiratory Society.