Abstract
The review article chronologically describes the development of opinions on "step-down" therapy of patients with chronic obstructive pulmonary disease (COPD). These are mainly pre-2014 GOLD documents warning against a worsening of symptoms and lung function as well as an increased risk for acute exacerbations due to discontinuation of inhaled corticosteroids (ICSs).
The GOLD recommendations are based on conclusions of studies such as COPE and COSMIC. The change in the opinion that "step-down" therapy is impossible was likely to occur after publishing of 2012 Spanish recommendations for management of stable COPD, stating that "step-down" therapy is possible in selected stable patients with certain COPD phenotypes (e.g.
ACOS). Considerations of ICS discontinuation and replacement with effective bronchodilators were supported in a meta-analysis by Nadeem.
Subsequently, the use of "step-down" therapy for COPD was confirmed by the OPTIMO, INSTEAD and, in particular, WISDOM studies. In the latter one, discontinuation of ICSs and their replacement with long-acting beta agonists or muscarinic antagonists did not significantly increase the risk for acute exacerbations in patients with moderate or severe COPD.
The question is, however, how clinically significant the related lung function and quality of life impairments are.