Deprescribing of inhaled corticosteroids in patients with COPD with mild or moderate airflow limitation: what do patients think?

Background: GOLD guidelines support the prescription of high-dose inhaled corticosteroids (HD-ICS) in symptomatic COPD patients with frequent or severe exacerbations. HD-ICS are frequently prescribed outside guidelines with the risk of side effects. No investigation of patients’ views of HD-ICS withdrawal have been conducted. Aim: To assess the views of COPD patients with mild or moderate airflow limitation to the staged withdrawal of HD-ICS prescribed outside guidelines with a view to a trial in primary care. Methods: One-to-one semi-structured qualitative interviews exploring COPD patients’ opinions and feelings about using HD-ICS prescribed outside guidelines and their attitudes to proposed withdrawal. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was completed. Results: Seventeen eligible COPD patients were interviewed. Twenty six expressed interest. 7 did not meet spirometry eligibility criteria. Two were unable due to illness. Many participants were not aware they were using a HD-ICS or of the risk of side effects. Some were unconcerned by what they perceived as low individual risk. Others expressed fears of worsening symptoms on withdrawal. Most with mild or moderate airflow limitation would have been willing to attempt withdrawal or titration to a lower dose of HD-ICS if advised by their clinician especially if a reasoned explanation was offered. Conclusions: Attitudes to discontinuing HD-ICS use are varied and likely to be complex. Proposed deprescribing requires detailed conversations between patients and respiratory healthcare professionals including acknowledgement of possible limited understanding of the medication.