Anti-inflammatory therapy in stable chronic obstructive pulmonary disease (COPD)
| ICS |
| 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) |
| Antibiotics |
| 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) |
| Mucolytics/antioxidants |
| 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.