Withdrawal of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease: A European Respiratory Society Guideline.

Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD. Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendation formulated by a committee with expertise in COPD and guideline methodology. After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of interventions, the guideline panel made: a) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations; b) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ⩾300 eosinophils·µL−1; c) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn. Conditional recommendations indicate that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.