Prescribing of inhaled high dose corticosteroids

Respiratory : Quality prescribing strategy - a guide for improvement
Scottish Government Effective Prescribing & Therapeutics Division
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Review patients with COPD following initiation of ICS as part of combination therapy after three months. 

 

  • The place of inhaled corticosteroids as part of combination therapy has been revised.47  For people with COPD who are at high risk of exacerbations, based on blood eosinophils of ≥300cells/μL, initial treatment with triple therapy (inhaled ICS plus LABA and LAMA) is recommended by GOLD.47
  • In addition, escalation to triple therapy is recommended if exacerbations occur in patients with blood eosinophils ≥300 cells/µL receiving monotherapy or patients with blood eosinophils ≥100 cells/μL receiving LABA + LAMA. 
  • If people with COPD also have a diagnosis of asthma, they should be treated according to treatment guidelines for asthma, with ICS.47

 

  • ICS (licensed only as part of combination therapy (with LABA and/or LAMA) are prescribed for people with COPD who have a severe exacerbation or more than two exacerbations in one year or if there are asthmatic features or features suggesting steroid responsiveness.47
  • ICS provide some benefit to patients with severe COPD, reducing exacerbations by 20-25% however there is a dose dependant risk of side effects (including pneumonia and osteoporosis).
  • Clinical review following initiation of ICS should be undertaken after three months and ICS stopped if there is insufficient response or if there are adverse effects.46
  • A blood eosinophil count ≥300 cells/microlitre is more likely to cause relapse or exacerbations if ICS is withdrawn and needs to be monitored carefully.
  • Refer to local guidelines to optimise treatment.

 

The chart below shows the variation in inhaled high dose corticosteroids between NHS Boards over the last three years. The high dose classification is based on SIGN 158.6

 

High dose corticosteroid inhalers as a percentage of all corticosteroid inhalers items (using 2019 SIGN/BTS classification of high dose)

 

 

Note: High dose ICS prescribing used in the data corresponds to the definition of high dose steroids (both for adults and children) as per Table 12 in SIGN 158.6

The numerical data for NTI graphs can also be viewed here.

The most up to date national therapeutic indicator data is available here.