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COUNSELLING IN PRACTICE
1. What is the main aim of using
inhaled corticosteroids in COPD?
a) To reduce the severity and duration of
b) To reduce the frequency of
c) To slow the rate of decline in lung
d) To reduce COPD-related mortality.
2. When are inhaled corticosteroids
recommended to be commenced in
a) As soon as possible after the initial
b) When the patient’s symptoms are not
adequately controlled by as-needed
c) When the patient’s symptoms are not
adequately controlled by regular use
of long-acting bronchodilators.
d) When the patient’s symptoms are not
adequately controlled by regular use
of long-acting bronchodilators plus
3. What are the indications for inhaled
corticosteroids in COPD?
a) An FEV1 ≤ 50% predicted.
b) Two or more exacerbations in the
preceding 12 months.
c) An FEV1 ≤ 50% predicted and an
exacerbation in the preceding 6
d) An FEV1 ≤ 50% predicted and two or
more exacerbations in the preceding
4. Which of the following is NOT a
likely adverse effect of inhaled
corticosteroids in a patient with
b) Oral thrush.
5. Which of the following statements
regarding COPD is CORRECT?
a) Chest tightness and wheezing are not
symptoms of COPD, and their presence
can help to distinguish between
asthma and COPD.
b) Exacerbations in COPD are most
commonly caused by air pollution or
changes in ambient temperature.
c) The only intervention that has been
shown to slow the rate of decline in
lung function in COPD is smoking
d) A patient with COPD whose lung
function improves following a short
course of oral prednisolone is likely to
benefit from an inhaled corticosteroid.
and using a spacer (for a metered dose
inhaler). You offer to demonstrate and check
his inhaler technique. You also inform Michael
that ICS can cause some more serious side
effects such as pneumonia and reduced
bone density, and may increase the risk of
developing diabetes. He will need to visit his
doctor regularly for check-ups and consult
the doctor as soon as possible if he starts
experiencing any troublesome symptoms.
You ask Michael if he still smokes. He says
he does, but not as heavily as he used to.
You explain that, although it is good that he
has cut down, it is vitally important for him to
stop smoking completely, and offer to assist
him in achieving this goal. You also advise
him to have a regular annual flu vaccine
and ensure that he is up-to-date with his
pneumococcal vaccines. You suggest that
he regularly check his COPD action plan so
that he knows exactly what to do and what
medicines to take if his symptoms worsen.
1. Global Initiative for Chronic Obstructive Lung Disease (GOLD).
Global strategy for the diagnosis, management and prevention of
COPD. 2013. At: www.goldcopd.org/guidelines-global-strategy-
2. Chronic obstructive pulmonary disease. In: eTG complete.
Melbourne: Therapeutic Guidelines; 2013.
3. McKenzie DK, Abramson M, Crockett AT et al. on behalf of The
Lung Foundation Australia. The COPD-X Plan: Australian and New
Zealand Guidelines for the management of Chronic Obstructive
Pulmonary Disease V2.30, 2011. At: www.copdx.org.au/the-copd-
Key learning points
ICS are not used as first-line therapy in
COPD because they are less effective
than long-acting bronchodilators.
However, when used as add-on
therapy in patients with severe
COPD, ICS can reduce the risk of
exacerbations and improve quality of
life symptoms such as dyspnoea and
cough. They may also improve some
measures of lung function and reduce
‘rescue’ bronchodilator use. ICS are
likely to be less effective in people
with COPD who continue to smoke.
In addition to local adverse
effects such as oral candidiasis
and hoarseness, ICS can cause
systemic adverse effects such as skin
bruising, cataracts, osteoporosis and
pneumonia. When deciding whether
to add an ICS to a COPD treatment
regimen, the potential benefits need
to be considered against the potential
risks. In general, patients most likely to
benefit from ICS are those who have
severe COPD (FEV1 ≤ 50% predicted)
and frequent exacerbations (≥ 2/year),
as well as those with mixed asthma
4. Rossi S, ed. Australian Medicines Handbook. Adelaide: AMH; 2013.
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obstructive pulmonary disease. BMJ 2012;345:e6843. At: www.
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long-acting beta2-agonist in one inhaler versus long-acting beta2-
agonists for chronic obstructive pulmonary disease. Cochrane
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7. Price D, Yawn B, Brusselle G, et al. Clinical review : Risk-to-benefit
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Care Respir J 2013;22(1):92–100. At: www.thepcrj.org/journ/
8. Loke YK, Cavallazzi R, Singh S. Risk of fractures with inhaled
corticosteroids in COPD: systematic review and meta-analysis of
randomised controlled trials and observational studies. Thorax
2011;66(8):699–708. At: http://thorax.bmj.com/content/66/8/699.
9. Ernst P, Gonzalez AV, Brassard P, et al. Inhaled corticosteroid
use in chronic obstructive pulmonary disease and the risk
of hospitalization for pneumonia. Am J Respir Crit Care Med
10. Suissa S, Kezouh A, Ernst P. Inhaled corticosteroids and the
risks of diabetes onset and progression. Am J Med 2010
Nov;123(11):1001–6 . At: www.amjmed.com/article/S0002-
11. O’Byrne PM, Rennard S, Gerstein H. Risk of new onset diabetes
mellitus in patients with asthma or COPD taking inhaled
corticosteroids. Resp Med 2012;106(11):1487–93 . At: www.
12. Yang IA, Clarke MS, Sim EHA, et al. Inhaled corticosteroids for
stable chronic obstructive pulmonary disease. Cochrane Database
of Systematic Reviews 2012, Issue 7. Art. No.: CD002991. DOI:
10.1002/14651858.CD002991.pub3. At: http://onlinelibrary.wiley.
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or chronic obstructive pulmonary disease. Cochrane Database
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for the treatment of chronic obstructive pulmonary disease. Br
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Guide. Melbourne: National Asthma Council Australia; 2011. At:
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