Withdrawal of inhaled corticosteroids in COPD patients with mild or moderate airflow limitation: who is suitable for a trial of withdrawal?

Background: Inappropriate use of high-dose inhaled corticosteroids (HD-ICS) increases pneumonia risk and other complications in patients with COPD. The main indication for prescription of HD-ICS is frequent exacerbations with symptomatic disease. There is a need to identify those patients who are inappropriately prescribed HD-ICS. Aim: Identify COPD patients with mild or moderate airflow limitation suitable for withdrawal of HD-ICS. Method: Electronic records search in UK primary care identified COPD patients (asthma excluded) recently prescribed HD-ICS with no recorded severe airflow limitation in the past year. Before assessment with a view to HD-ICS withdrawal each record was scrutinised. Patients were excluded if prescription of HD-ICS was justified. Eligible patients invited by their family doctor for COPD review. Results: 392 suitable records were identified by electronic search from a COPD patient population of 2967. Frequent inconsistencies in diagnosis and recording of exacerbations were seen in patient notes, often with inability to assign prescription (rescue packs) of antibiotics and prednisolone to exacerbation occurrence. 243 patients excluded from withdrawal as HD-ICS justified. Predominant exclusion factors were: moderate or severe exacerbations (35%), severe airflow obstruction (27%), airflow reversibility (6%), active lung cancer (4%), dementia (3%). 149 patients invited for COPD review. 61 attended, 27 declined in writing, 61 not contactable or refused on the telephone. Conclusion: The determinants of suitability for HD-ICS prescription in primary care records are inconsistently recorded, difficult to identify and challenging to apply.