LAMA and ICS discontinuation in COPD: run-in to an exacerbation?

Long-acting muscarinic antagonists (LAMAs) and inhaled corticosteroids (ICS) have long been foundational in COPD management. LAMAs, through their bronchodilatory effects, are well known to improve health-related quality of life and reduce exacerbation rates,1 potentially by reducing hyperinflation.2 ICS therapy has been widely recognised for its role in controlling airway inflammation and preventing exacerbations in patients with COPD, particularly in those with elevated blood eosinophil counts.3 4 ICS, however, are frequently prescribed to patients with COPD without a clear indication, and given their (long-term) side effects, the 2020 European Respiratory Society ICS withdrawal guideline5 meticulously formulated recommendations in whom to withdraw ICS and in whom not to, based on exacerbation history and blood eosinophil counts. There are no such arguments urging the withdrawal of maintenance LAMA, provided they are tolerated by the patient. Yet, in daily life, failing or varying inhaler therapy compliance over time probably leads to actual ‘withdrawal’—or intermittent withdrawal episodes at the least. In this edition of Thorax , Mathioudakis et al present a valuable non-prespecified exploratory post hoc analysis with data from the 2016 Effect of Indacaterol Glycopyrronium vs. …