Personalized medicine approach for COPD treatment

ICS in COPD: Are We Finally Ready to Tailor Treatment?

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Lena Kashyap in Health & Wellness December 2025 • 5 min read.

"New insights suggest personalized approaches to inhaled corticosteroid (ICS) use in COPD could improve outcomes and minimize risks."


For over half a century, inhaled corticosteroids (ICS) have been a mainstay in managing chronic obstructive pulmonary disease (COPD). With decades of research and numerous large-scale trials involving over 40,000 patients, the role of ICS in COPD treatment has been a subject of ongoing debate. While ICS can reduce the risk of exacerbations, their benefits are modest, and they carry potential risks, most notably an increased risk of pneumonia.

The combination of ICS with a long-acting β2-agonist (LABA) has shown promise in improving symptoms and reducing exacerbations compared to either drug alone. However, questions remain about whether this combination is superior to long-acting muscarinic antagonists (LAMA) alone or in combination with LABA (i.e., LABA/LAMA). Current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines offer various options for symptomatic COPD patients with frequent exacerbations, leaving clinicians to navigate choices like LAMA, LABA/LAMA, ICS/LABA, or even ICS/LABA/LAMA combinations.

This ambiguity often leads to therapeutic decisions based on personal preference or habit rather than solid evidence. Experts have criticized this approach, calling for a shift towards "precision medicine" in COPD management. Now, emerging research is shedding light on how to target ICS therapy to the right patients at the right time, potentially optimizing benefits while minimizing harm.

Who Benefits Most from ICS in COPD? Asthma History and Eosinophil Counts

Personalized medicine approach for COPD treatment

Recent studies highlighted in the European Respiratory Journal (ERJ) suggest that ICS should primarily be prescribed to COPD patients with a history of asthma or features indicative of asthma-COPD overlap. As noted by Suissa and Ariel, the inclusion or exclusion of asthma-COPD overlap patients in clinical trials may explain inconsistencies in the outcomes of ICS-containing therapies. Trials like IMPACT and TRIBUTE, which included patients with a prior history of asthma, demonstrated reduced exacerbation rates with ICS-containing combinations.

Conversely, the FLAME trial, which excluded patients with asthmatic features, found that LABA/LAMA therapy was associated with lower exacerbation rates compared to ICS/LABA. Furthermore, an analysis by Suissa and Ariel revealed a transient surge in exacerbation rates in the ICS-free arms of these trials during the first month after ICS withdrawal. This observation suggests that abrupt ICS discontinuation without proper supplementation may lead to exacerbations.

  • Asthma-COPD Overlap: Patients with features of both asthma and COPD tend to respond well to ICS.
  • Eosinophil Count: Individuals with higher eosinophil counts (≥300 cells per μL) are more likely to benefit from ICS.
  • Withdrawal Considerations: Abruptly stopping ICS can lead to a temporary increase in exacerbations.
While ICS can increase the risk of pneumonia, Cazzola et al. addressed the balance between the benefits of ICS for exacerbation prevention and the potential harm of pneumonia. Using the SUCRA method, they found that LABA/LAMA combination was generally favored over ICS/LABA/LAMA and LABA or LAMA alone. However, the effects of ICS therapy are modified by peripheral blood eosinophil count. Patients with blood eosinophil counts of ≥300 cells per µL are much more likely to be responsive to ICS-based therapy than those with lower eosinophil counts.

Personalizing COPD Treatment: A Path Forward

While these findings offer valuable insights, many questions regarding the role of ICS in COPD management remain. Future studies should rigorously test whether newer-generation ICS-based therapies, delivered via ultrafine devices, may prolong survival, particularly in patients with comorbidities. Additionally, the effects of ICS-based therapy on hospitalizations, a major driver of direct costs for COPD care, warrant further investigation. As research progresses, a deeper understanding of COPD pathogenesis and the identification of novel therapeutic targets will pave the way for precision medicine approaches that improve outcomes and quality of life for millions affected by this chronic respiratory condition.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1183/13993003.01940-2018, Alternate LINK

Title: Inhaled Corticosteroids In Copd: The Final Verdict Is…

Subject: Pulmonary and Respiratory Medicine

Journal: European Respiratory Journal

Publisher: European Respiratory Society (ERS)

Authors: Janice M. Leung, Don D. Sin

Published: 2018-12-01

Everything You Need To Know

1

What are inhaled corticosteroids and what role do they play in COPD treatment?

Inhaled corticosteroids, or ICS, are medications used in chronic obstructive pulmonary disease, or COPD, to reduce the risk of exacerbations. While they have been a mainstay treatment for over half a century, their benefits are modest, and they carry potential risks, most notably an increased risk of pneumonia. ICS are often combined with a long-acting β2-agonist, known as LABA, to improve symptoms and reduce exacerbations.

2

What is the significance of combining ICS with LABA in COPD management?

The combination of an inhaled corticosteroid, or ICS, with a long-acting β2-agonist, known as LABA, aims to improve symptoms and reduce exacerbations in COPD patients. This combination is significant because it addresses both bronchodilation (through LABA) and inflammation (through ICS). However, it's essential to consider whether this combination is superior to other treatments, such as long-acting muscarinic antagonists, or LAMA, alone or in combination with LABA, because of the side effects from the ICS.

3

Which COPD patients are most likely to benefit from ICS?

Patients who have both asthma and COPD, a condition known as asthma-COPD overlap, tend to respond well to inhaled corticosteroids, known as ICS. Also, individuals with higher eosinophil counts (≥300 cells per μL) are more likely to benefit from ICS. Identifying these patient subgroups is crucial for personalizing COPD treatment and maximizing the benefits of ICS therapy while minimizing potential harm.

4

What happens if a patient abruptly stops using ICS?

Abruptly stopping inhaled corticosteroids, or ICS, can lead to a temporary increase in exacerbations. This suggests that when discontinuing ICS, it should be done gradually and with proper supplementation. Monitoring patients closely during and after ICS withdrawal is important to manage any potential exacerbations and ensure a smooth transition to alternative therapies if needed.

5

How does eosinophil count affect ICS treatment?

Peripheral blood eosinophil count affects how effective inhaled corticosteroids (ICS) can be. People with more than or equal to 300 cells per µL of blood eosinophils respond more favorably to ICS-based treatment than those with lower eosinophil counts. The use of blood eosinophil counts helps to target ICS to those most likely to benefit while minimizing treatment for those who are not.

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