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Current national and international guidelines recommend the use of inhaled corticosteroids (ICS) in addition to long-acting bronchodilators in people with more severe COPD to reduce the risk of exacerbations. Opinions on the benefits and role of ICS in COPD have changed considerably over the last 25 years. In the 1980s, they were widely used in Europe by extrapolation from their role in asthma. Indeed, it was thought that they might have long-term disease modifying potential and the ISOLDE study was undertaken to investigate this.1 ISOLDE showed no overall effect on the rate of decline in FEV1, but did for the first time raise the possibility that ICS had an effect on the occurrence of exacerbations.
Perhaps surprisingly, some long-acting bronchodilators were also found to reduce the risk of moderate and severe exacerbations compared with placebo. In a meta-analysis, this reduction in severe exacerbations requiring hospitalisation was over 25% in the long-acting β agonist (LABA) group compared with placebo.2 Some evidence suggests that long-acting antimuscarinics (LAMAs) are even more effective than LABAs at reducing exacerbations compared with placebo.3 ,4
Subsequently, studies investigated the effect of combinations of ICS with LABA bronchodilators and showed that the rate of exacerbations was reduced by both ICS and LABA but that the combination was more effective.5 The effect appeared to be most marked in people with an FEV1 less than 50% predicted. Recognition of the importance of exacerbations as key events in the course of COPD was also growing at this time, with studies showing that they were key determinants of health status and associated with a faster decline in lung function. Both from a patient and a health service perspective, prevention of exacerbations became a key objective of COPD management.
Unlike asthma management, COPD pharmacotherapy has largely …
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