Reassessing Long-Term ICS Use in COPD: Weighing Relief Against Risk

Inhaled corticosteroids (ICS) have long been a cornerstone in managing chronic obstructive pulmonary disease (COPD), prized for their ability to reduce airway inflammation and mitigate exacerbations. But as the use of ICS becomes more entrenched in long-term treatment plans, a deeper look into their cumulative effects is surfacing concerns that extend beyond the lungs.

Recent findings published in BMJ Open Respiratory Research point to a troubling association: COPD patients receiving ICS therapy for longer than 24 months face significantly elevated risks of developing type 2 diabetes, cataracts, pneumonia, osteoporosis, and nontraumatic fractures. These results cast a critical spotlight on the delicate balance between therapeutic benefit and unintended harm—particularly relevant for pulmonologists and primary care physicians who often serve as gatekeepers in the long-term care of these patients.

Historically, ICS have played an essential role in controlling COPD symptoms, particularly in patients with frequent exacerbations or elevated eosinophil counts. Their anti-inflammatory action offers substantial relief for many, especially when paired with long-acting bronchodilators. However, with evidence mounting against prolonged ICS use in certain populations, clinicians are being urged to reconsider blanket prescribing strategies.

The study in question drew from large-scale observational cohorts to quantify the risk differential between long- and short-term ICS exposure. Among COPD patients who used ICS for over two years, hazard ratios for composite adverse outcomes—including metabolic, skeletal, and infectious complications—were markedly elevated: 2.65 in the prevalent cohort and 2.60 in the inception cohort. The risk for recurrent pneumonia was even higher, with hazard ratios of 2.88 and 2.85, respectively. Nontraumatic fractures also showed a clear increase, particularly among older adults already vulnerable to falls and bone loss.

This data underscores an uncomfortable but necessary truth: the benefits of ICS in COPD are not universally enduring. For certain patients, especially those without a history of exacerbations or with low eosinophil counts, the risk profile may outweigh the therapeutic gains. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has already begun to reflect this thinking, recommending more tailored use of ICS based on exacerbation history and biomarkers of inflammation.

What does this mean in practice? It means clinicians must go beyond standardized protocols to assess each patient’s risk-benefit ratio over time. In many cases, stepping down or withdrawing ICS—when clinically appropriate—may help reduce the burden of side effects. It also demands more vigilant monitoring, particularly for signs of hyperglycemia, visual disturbances, recurrent infections, or declining bone density.

Moreover, alternative treatment pathways are gaining traction. Dual bronchodilation with long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMA) has shown promise in managing symptoms and reducing exacerbations without the added systemic risks of corticosteroids. For patients with overlapping asthma-COPD features, ICS may remain indispensable, but for others, periodic re-evaluation is not just advisable—it’s imperative.

Ultimately, the message is clear: inhaled corticosteroids still have a role, but it’s one that should be more precisely defined. This shift calls for clinicians to adopt a more discerning, personalized approach—leveraging clinical markers, patient history, and evolving evidence to determine who truly benefits from long-term ICS therapy and who might fare better with a revised strategy.

As we move forward, the challenge will lie in translating population-level data into actionable, patient-level decisions. But the goal remains consistent: to offer relief from the burdens of COPD without introducing avoidable harm. And that begins with asking not just if ICS are helping—but how, for how long, and at what cost.