COPD: Withdrawal of ICS vs Continuation of Triple Therapy (LAMA/LABA/ICS)

Sarfaroj Khan 


January 28, 2021


  • In patients with chronic obstructive pulmonary disease (COPD), composed mostly of infrequent exacerbators, discontinuation of inhaled corticosteroid (ICS) from triple therapy (TT; long-acting muscarinic antagonist [LAMA]+long-acting beta2-agonist [LABA]+ICS) was not associated with an increased risk of exacerbation.

  • However, the risk of reinitiating ICS or suffering an exacerbation was significantly increased in subgroup of patients with blood eosinophil count ≥300 cells/μL and having more oral corticosteroid (OCS) prescriptions in the year prior to ICS cessation.

Why this matters

  • Discontinuation of ICS from TT is still very infrequent in primary care.

  • Findings support the recommendations that ICS withdrawal should be considered in patients without a history of frequent exacerbations and low blood eosinophil counts.

Study design

  • This observational comparative effectiveness study included 1046 patients who withdrew ICS matched 1:4 by time on TT to 4184 patients who continued with TT over a period of 1 year of observation from the UK Optimum Patient Care Research Database (OPCRD).

  • 76.1% of patients had 0 or 1 exacerbation the previous year.

  • Primary outcome: time to first COPD exacerbation.

  • Funding: Boehringer Ingelheim.

Key results

  • After controlling for confounders, cessation of ICS was not associated with an increased risk of moderate or severe exacerbations (adjusted HR, 1.04; 95% CI, 0.94-1.15; P=.441).

  • Rates of exacerbations managed in primary care (incidence rate ratio [IRR], 1.33; 95% CI, 1.10-1.60; P=.003) or in hospital (IRR, 1.72; 95% CI, 1.03-2.86; P=.036) were significantly higher in the ICS withdrawal group.

  • The odds of successful ICS withdrawal were significantly reduced with:

    • blood eosinophil count ≥300 cells/μL (aHR, 0.50; 95% CI, 027-0.91; P=.023); and

    • frequent courses of OCS in the year prior to ICS cessation.

      • 2 prescriptions (aHR, 0.23; 95% CI, 0.11-0.44; P<.001).

      • >3 prescriptions (aHR, 0.31; 95% CI, 0.19-0.47; P<.001).


  • Observational design.

  • Risk of bias.


Magnussen H, Lucas S, Lapperre T, Quint JK, Dandurand RJ, Roche N, Papi A, Price D, Miravitlles M. Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study. Respir Res. 2021;22(1):25. doi: 10.1186/s12931-021-01615-0. PMID: 33478491 View abstract

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.


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