Anti-inflammatory therapy in stable chronic obstructive pulmonary disease (COPD)

 An ICS combined with a LABA is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with exacerbations and moderate to very severe COPD (evidence A)
 Regular treatment with ICS increases the risk of pneumonia especially in those with severe disease (evidence A)
 Triple inhaled therapy of ICS/LAMA/LABA improves lung function, symptoms and health status (evidence A) and reduces exacerbations (evidence B) compared to ICS/LABA or LAMA monotherapy
Oral glucocorticoids
 Long-term use of oral glucocorticoids has numerous side-effects (evidence A) with no evidence of benefits (evidence C)
PDE4 inhibitors
 In patients with chronic bronchitis, severe to very severe COPD and a history of exacerbations
  A PDE4 inhibitor improves lung function and reduces moderate and severe exacerbations (evidence A)
  A PDE4 inhibitor improves lung function and decreases exacerbations in patients who are on fixed-dose LABA/ICS combinations (evidence B)
 Long-term azithromycin and erythromycin therapy reduces exacerbations over 1 year (evidence A)
 Treatment with azithromycin is associated with an increased incidence of bacterial resistance (evidence A) and hearing test impairment (evidence B)
 Regular use of NAC and carbocysteine reduces the risk of exacerbations in select populations (evidence B)
Other anti-inflammatory agents
 Simvastatin does not prevent exacerbations in COPD patients at increased risk of exacerbations and without indications for statin therapy (evidence A); however, observational studies suggest that statins may have positive effects on some outcomes in patients with COPD who receive them for cardiovascular and metabolic indications (evidence C)
 Leukotriene modifiers have not been tested adequately in COPD patients

ICS: inhaled corticosteroid; LABA: long-acting β2-agonist; LAMA: long-acting muscarinic antagonist; PDE: phosphodiesterase; N-acetylcysteine.