Withdrawal of inhaled corticosteroids in COPD : A meta-analysis

Background Conflicting findings exist on the benefit of withdrawal of inhaled corticosteroid (ICS) in chronic obstructive pulmonary disease (COPD). We performed a quantitative synthesis in order to assess real impact of ICS discontinuation in COPD patients. Methods We carried out a meta-analysis via random-effects model on the available clinical evidence to evaluate the effect of ICS discontinuation in COPD. Randomized clinical trials and observational real-life studies investigating the effects of ICS withdrawal on the risk of COPD exacerbation, lung function (forced expiratory volume in 1 s [FEV1]) and quality of life (St. George's Respiratory Questionnaire [SGRQ]) were identified by searching from published studies and repository databases. Results ICS withdrawal did not significantly (P > 0.05) increase the overall rate of COPD exacerbation, although a clinically important increased risk of severe exacerbation was detected (Relative Risk >1.2). ICS withdrawal significantly (P < 0.001) impaired both lung function (−30 ml FEV1) and quality of life (+1.24 SGRQ units), although in a non-clinically important manner. The time to the first exacerbation was significantly (P < 0.05) shorter in the patients who discontinued ICS. Conclusions The discrepancy between statistical analysis and clinical interpretation of this meta-analytic evaluation demonstrates the strong clinical need in understanding what is the real impact of ICS withdrawal in COPD. ICS discontinuation is a complex procedure that requires a well planned and tailored strategy. Further well designed studies on withdrawal of ICS should be performed by clustering COPD patients with regard to the phenotype characteristics, rate of exacerbations/year, decline of lung function, and quality of life.