High-dose ICS refers to a total daily dose equal to or greater than 1,000 micrograms beclometasone dipropionate (BDP) equivalent. Therefore, it is important to have an understanding of the potency of ICS when starting and reviewing therapy.  

For asthma, ICS should be used at the lowest effective dose to manage symptoms, so it would be reasonable to do the same for COPD or asthma/COPD overlap. However, sometimes there are practical difficulties in applying this due to the various fixed-dose inhaler combinations available on the market.  

No trials have been carried out to investigate the optimum dose of ICS in the management of COPD. There is no data suggesting that higher doses of ICS are associated with better outcomes or greater reduction in exacerbations; doses used in practice need to be weighed up against the overall risk of side effects and the impact on the person using them. Consider the licensed indications and doses for different inhalers. Note that there is no evidence for using ICS alone (without a long-acting bronchodilator) in someone with COPD and such use should be questioned.

There is some evidence that the risk of pneumonia related to ICS use is higher when using higher doses and higher-potency corticosteroids. For example, fluticasone propionate and furoate are much more potent than BDP, and extrafine particle formulations of BDP are more potent than standard BDP. Caution should be exercised when prescribing ICS and pharmacy professionals should actively question high doses to prevent unnecessary steroid exposure.

Steroid treatment cards should be given and discussed with patients when dispensing high-dose ICS. Consider a steroid treatment card for patients taking intermediate-dose ICS of 800-1,000 micrograms total daily dose BDP equivalent.