Inhaled steroids for stable chronic obstructive pulmonary disease

Steroid preventer medications given by inhaler ('inhaled steroids') help to reduce inflammation in the air passages of people with asthma. However, it is uncertain whether these medications are beneficial in people with chronic obstructive pulmonary disease (COPD, i.e. chronic bronchitis or emphysema or both).

We undertook a systematic review of the benefits and safety of inhaled steroids for people with COPD. Our review analysed the effects on breathing capacity, death rates, frequency of flare-ups ('exacerbations'), quality of life and side effects.

Pooling of the data from the 55 trials with 16,154 people showed that there was no consistent long-term benefit in the rate of decline in breathing capacity. Death rates were unchanged. Inhaled steroids were beneficial in slowing down the rate of decline in quality of life and reducing the frequency of exacerbations. Inhaled steroids increased the risk of side effects including thrush (candida) infection in the mouth and hoarseness, and the rate of pneumonia.

In deciding whether to use this treatment, consumers and health professionals should weigh up the benefits (reduced rate of exacerbations, reduced decline in quality of life and possible reduction in the rate of decline of breathing capacity) against the side effects (mouth thrush, hoarseness and increased risk of developing pneumonia).

Authors' conclusions: 

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life and possibly reduced rate of decline in FEV1) against the potential side effects (oropharyngeal candidiasis and hoarseness, and risk of pneumonia).

Read the full abstract...

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.


To determine the efficacy and safety of inhaled corticosteroids in stable patients with COPD, in terms of objective and subjective outcomes.

Search strategy: 

A pre-defined search strategy was used to search the Cochrane Airways Group Specialised Register for relevant literature. Searches are current as of July 2011.

Selection criteria: 

We included randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta2-agonists and bronchial hyper-responsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. We also analysed data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety.

Data collection and analysis: 

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

Main results: 

Fifty-five primary studies with 16,154 participants met the inclusion criteria. Long-term use of ICS (more than six months) did not consistently reduce the rate of decline in forced expiratory volume in one second (FEV1) in COPD patients (generic inverse variance analysis: mean difference (MD) 5.80 mL/year with ICS over placebo, 95% confidence interval (CI) -0.28 to 11.88, 2333 participants; pooled means analysis: 6.88 mL/year, 95% CI 1.80 to 11.96, 4823 participants), although one major trial demonstrated a statistically significant difference. There was no statistically significant effect on mortality in COPD patients (odds ratio (OR) 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long-term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: MD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants; pooled means analysis: MD -0.19 exacerbations per patient per year, 95% CI -0.30 to -0.08, 2253 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.65, 95% CI 2.03 to 3.46, 5586 participants) and hoarseness. In the long-term studies, the rate of pneumonia was increased in the ICS group compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.56, 95% CI 1.30 to 1.86, 6235 participants). The long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years.