A 74-year-old man comes to the physician because of daily productive cough with yellowish sputum and dyspnea on exertion. His past medical history includes chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, and hyperlipidemia. Over the last 6 months, he has had 2 hospital admissions for respiratory distress. The most recent admission was 2 months ago, when he was treated with IV corticosteroids and bronchodilators via nebulizer. His medications include formoterol and tiotropium. The patient's dyspnea has improved since discharge but he is short of breath with exertion. He has lost 10 lb (4.5 kg) over the last 6 months. He stopped smoking 7 years ago but has a 60-pack-year history.
Pulse oximetry is 93% on room air. He is notably dyspneic after walking down the hall. Physical examination shows a thin man with bitemporal wasting. His chest is barrel shaped. There is mild diffuse expiratory wheezing on lung examination.
Pulmonary function testing is significant for FEV₁ 35% of predicted, FVC 55% of predicted, FEV₁/FVC 63%, and lung diffusion capacity testing 43% of predicted. Chest x-ray reveals hyperinflation.
Inhaled corticosteroids are added to his regimen during this clinic visit.
Which of the following do inhaled corticosteroids increase?

Question

Quizplus · Accepted Answer

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines COPD according to airflow limitation that is not fully reversible and abnormal inflammatory response of the lungs to noxious particles. Inhaled corticosteroids (ICS) can decrease this inflammatory response but are not recommended for stable COPD as long-acting bronchodilators have more benefit with fewer adverse effects. However, ICS are recommended in symptomatic COPD patients with frequent exacerbations who do not respond to treatment with inhaled bronchodilators, pulmonary rehabilitation, and smoking cessation. ICS may also help COPD patients who appear to have an asthmatic component. Regular treatment with ICS may improve symptoms, lung function, and quality of life. ICS also reduce the frequency of COPD exacerbations in patients with FEV₁ < 60% of predicted value (Choice C). Side effects include oral candidiasis, hoarse voice, skin bruising, and slightly increased risk of pneumonia. There are conflicting studies regarding incidence of cataracts and diminished bone density. Patients in those studies were also on systemic corticosteroids that may have increased the risk of cataracts and fractures. ₁ The TORCH (TOwards a Revolution in COPD Health) trial showed that ICS use did not increase all-cause or cardiovascular mortality or incidence of lung cancer during a 3-year follow-up period (Choices A, B & D). However, monotherapy with ICS was associated with a small but statistically insignificant increase in mortality. Hence, ICS should not be used alone but instead combined with a long-acting beta agonist. Educational objective: Inhaled corticosteroids (ICS) improve symptoms, lung function, and quality of life. ICS also reduce frequency of exacerbations in patients with COPD with an FEV₁ < 60% of predicted value. They should be used in conjunction with long-acting beta agonists. Major side effects are dysphonia, skin bruising, oral candidiasis, and slightly increased risk of pneumonia. ₁ __________ References: Inhaled corticosteroids in COPD: a controversy. (http://www.ncbi.nlm.nih.gov/pubmed/20501985) An overview of the benefits and drawbacks of inhaled corticosteroids in chronic obstructive pulmonary disease. (http://www.ncbi.nlm.nih.gov/pubmed/20714372)

A 74-Year-Old Man Comes to the Physician Because of Daily