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Interventions to de-escalate use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) are necessary and beneficial, researchers said during the federal posters session at the American Society of Health-System Pharmacists (ASHP) Midyear virtual meeting.

The recommend long-acting beta2-agonists (LABA) and long-acting muscarinic antagonists (LAMA) for the primary treatment of COPD. ICS have , despite being recommended only as an add-on therapy. Due to their association with and , the GOLD guidelines recommend de-escalation of ICS in some patients.

Prescribing Patterns for ICS

In one study of 70 patients who were prescribed an ICS for COPD, half were eligible for de-escalation. In addition, 50% of patients were found to have elevated risk of ICS-related pneumonia, reported Abegale Nelson, PharmD, of the Veteran Affairs (VA) Hudson Valley Healthcare System in New York.

Of the 70 patients, 60% were not prescribed a LAMA.

"Inappropriate use of ICS and underutilization of LAMA for patients with COPD is a problem at our facility," Nelson noted.

The study included 512 patients who had an ICS prescription coded for COPD; 70 were randomly selected for manual chart review. Mean age of the selected patients was 73, and 67 were men.

Nelson acknowledged that potentially inaccurate asthma or COPD diagnoses may have been included in the study, which was a limitation.

Using these data, Nelson and colleagues plan to carry out a de-escalation effort in the upcoming year.

Effects of De-Escalation

In a retrospective chart review to evaluate de-escalation status in 45 patients, ICS de-escalation was associated with an improvement in patient-reported COPD symptoms, said Jennifer Ngo, PharmD, of the Bay Pines VA Healthcare System in Florida.

In 19 patients who completed de-escalation, the average change in COPD Assessment Test score, which measures the impact of symptoms, improved by 3.4 points after de-escalation.

However, the majority of patients (26 of 45) did not complete ICS de-escalation. The primary reason for this lack of completion was non-compliance to scheduling attempts (10 patients), Ngo said.

These patients were identified for de-escalation by a Patient Aligned Care Team clinical pharmacy specialist from December 2020 to April 2021. Average age was 73.1 years, and all but one were men. One patient experienced an exacerbation of symptoms since de-escalation of ICS.

Ngo acknowledged that a limitation to the study was that symptom rating scores are patient-reported and can be influenced by outside factors. The team also evaluated changes in forced expiratory volume, but data were only available for one patient.

Future studies should consider how to improve adherence to ICS de-escalation programs, Ngo added.