Do or don’t? Inhaled steroids for COPD patients

Not all patients with COPD benefit from inhaled corticosteroids (ICS), and antibiotics are by no means always indicated in exacerbations. Therefore, a differentiated approach is recommended.

Controversies in pneumology

Not all patients with COPD benefit from inhaled corticosteroids (ICS), and antibiotics are by no means always indicated in exacerbations. A differentiated approach is recommended, according to the session "Controversies in Pneumology" during the digital edition of the German Society of Internal Medicine (DGIM) congress.

The guidelines recommend using inhaled steroids rather cautiously in COPD. However, in the view of Prof. Johann Christian Virchow, (Rostock University Hospital, Germany), restraint in prescribing inhaled steroids causes more harm than good. Prof. Virchow recommended considering ICS at any stage of COPD, especially (but not exclusively) when:

However, Prof. Virchow also said that caution should be exercised in the presence of a low BMI. ICS are also contraindicated in the presence of emphysema (CT confirmed) without exacerbations, and in the classic pink puffer (severe emphysema).

Regarding the cost-benefit ratio, Prof. Virchow said that therapy with ICS is no longer that expensive. If, on the other hand, patients end up in the hospital due to an acute exacerbation of COPD, that indeed mounts to higher costs, he said.

Prof. Dr. Henrik Watz (Pneumological Research Institute, LungenClinic Grosshansdorf, Germany) however, pointed out that for the majority of patients with COPD, therapy with inhaled steroids is not indicated anyway. This is because COPD is still a neutrophil-inflammatory respiratory disease, but anti-inflammatory effects of ICS on neutrophilic inflammation are not molecularly possible. In addition, pneumonias are more common under ICS. However, Prof. Watz also confirmed that ICS therapy is indicated in cases of frequent exacerbations and blood eosinophilia.

Incidentally, the hygiene measures in the context of the COVID-19 pandemic have also had a positive effect in COPD: they have led to a decrease in acute exacerbations, confirmed both Prof. Watz and Prof. Virchow.

Antibiotics in acute COPD exacerbation: yes or no?

Acute exacerbations significantly fuel the COPD vicious circle and thus disease worsening. Prof. Martin Witzenrath (Charité University Hospital, Berlin), therefore also advocated the use of antibiotics to prevent acute exacerbations.

A 2018 Cochrane review concluded that antibiotics can reduce acute exacerbations in COPD (AE-COPD) by up to 81%; ICU patients especially benefit from antibiotic administration. If there are signs of a bacterial exacerbation, patients generally benefit from an antibiotic, according to Prof. Witzenrath. The side effects of short-term antibiotic therapy (3 to 5 days) on the microbiome are negligible, he said.

Prof. Dr. Gernot Rohde, Frankfurt University Hospital (Universitätsklinikum Frankfurt), takes a critical view of the role of antibiotics in acute exacerbations. To a large extent, exacerbations are triggered by infections, some of which are bacterial, but others are also viral.

Current guidelines recommend the following approach in acute exacerbation:

For antibiotics, there are few to no controlled trials, Prof. Rohde emphasized. The increasing resistance to antibiotics also speaks against antibiotic therapy, as do side effects such as disturbed gut flora and, as a result, diarrhea or infection with Clostridioides difficile (CDI). Antibiotics (ABs) should not usually be used to treat acute exacerbations of COPD (AE-COPD) because:

Both agreed to give an antibiotic only when there is an indication to do so. But which patients should receive antibiotics and which should not?

Antibiotics in patients with purulent sputum and elevated C-reactive protein (CRP)

For example, should COPD patients with purulent sputum and four exacerbations be treated with an antibiotic? Prof. Rohde reminded that purulent sputum does not automatically indicate an acute bacterial infection. It could also be an expression of bronchial colonization or simply be present due to neutrophils discoloring the sputum. Nevertheless, some studies have shown that there is a correlation between purulent sputum and positive bacterial culture, and Prof. Rohde added that "however, we don't know if these bacteria are precisely the trigger of the exacerbation." The level of inflammation is indicative of a bacterial infection, he said. If patients have significantly elevated inflammatory parameters, leukocytosis, or CRP above 50, an antibiotic should rather be prescribed. The severity of the exacerbation, for example whether the patient is still under respiratory insufficiency, is also decisive.

Prof. Witzenrath emphasized that in all patients it must be considered whether an infection is causing the exacerbation at all or whether something else is the underlying cause. For example, cardiac function must be clarified. If one can assume an infection, it is to be examined whether patients exhibit further dyspnea, and whether more purulent sputum than normally occurs (not only in the morning but throughout the day). For Prof. Witzenrath, these are indications that are more likely to point to a bacterial infection. If the CRP is elevated and is above 30, patients have already had to deal with a bacterial exacerbation more often, and hence, Prof. Witzenrath would rather prescribe an antibiotic.

In patients who have more frequent acute exacerbations, an high-resolution computed tomography (HRCT) is worthwhile. If these patients show bronchiectasis, an antibiotic should be administered. As Prof. Rohde confirmed, an antibiotic is then usually indicated for each exacerbation.

References:
127th Annual Meeting of the German Society of Internal Medicine. (DGIM) Session: Controversies in Pneumology, April 19, 2021, 1 to 2:15 p.m.

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