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COPD treated with inhaled corticosteroids — SCE Respiratory MCQ

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HardPneumonia RiskCOPD treated with inhaled corticosteroidsSCE Respiratory

A 72-year-old man with smoking-related COPD is reviewed 8 weeks after his second radiographically confirmed pneumonia requiring hospital admission within 14 months. His consolidation has resolved, and CT shows severe centrilobular emphysema without bronchiectasis, an obstructing lesion or interstitial lung disease. He currently smokes 10 cigarettes daily and has a BMI of 18.2 kg/m². Post-bronchodilator FEV1 is 34% predicted. He has no previous diagnosis of asthma, childhood wheeze or atopy, and bronchodilator reversibility is 4%. Four blood eosinophil counts obtained when clinically stable and without recent systemic corticosteroid exposure have ranged from 40 to 90 cells/µL. He takes once-daily fluticasone furoate/umeclidinium/vilanterol with good adherence and inhaler technique. Triple therapy was started 3 years ago because of the severity of airflow obstruction, although he had experienced no exacerbations in the preceding year. He has subsequently had no moderate or severe COPD exacerbations. His exertional breathlessness is stable, and there is no clinical evidence of an acute exacerbation. Which long-term inhaled treatment strategy is most appropriate?

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Correct answer: E — Withdraw fluticasone furoate and continue umeclidinium/vilanterol

Explanation lettering: D = shown as A · A = shown as C · C = shown as D

The appropriate strategy is withdrawal of the inhaled corticosteroid while maintaining dual long-acting bronchodilation. The original indication for triple therapy was weak: severe airflow obstruction alone does not establish corticosteroid responsiveness. He has no asthma or atopic phenotype, no relevant exacerbation history and repeatedly has eosinophils well below 300 cells/µL. ERS guidance supports ICS withdrawal in COPD without frequent exacerbations, recommends against withdrawal when eosinophils are at least 300 cells/µL, and recommends one or two long-acting bronchodilators after withdrawal. ([publications.ersnet.org](https://publications.ersnet.org/content/erj/55/6/2000351?ctkey=shareline&utm_source=openai)) His recurrent pneumonia materially shifts the benefit–harm balance. ICS use in COPD is associated with pneumonia, while older age, current smoking, low BMI and severe COPD further increase pneumonia risk. ([nice.org.uk](https://www.nice.org.uk/guidance/ng115/chapter/Recommendations?utm_source=openai)) A exposes him to continued ICS risk without a demonstrated indication. B reduces exposure but retains an unnecessary drug. C is tempting because some comparative studies suggest differing pneumonia rates, but the UK product information states that conclusive evidence of an ICS intraclass difference is lacking; moreover, changing ICS does not correct the absent indication. D retains the component most suitable for withdrawal and sacrifices established dual bronchodilation. Following ICS withdrawal, symptoms, lung function and exacerbation frequency should be monitored.

Reference: Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline (4 June 2020) — https://publications.ersnet.org/content/erj/55/6/2000351 Chronic obstructive pulmonary disease in over 16s: diagnosis and management — Recommendations (Published 5 December 2018; last clinical update 26 July 2019) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations Trelegy Ellipta 92 micrograms/55 micrograms/22 micrograms inhalation powder — Summary of Product Characteristics (Text revised 2 June 2025) — https://www.medicines.org.uk/emc/medicine/34357/spc