Administration of inhaled glucocorticoids for patients with stable COPD must again be carefully considered because of possible side effects. Oropharyngeal candidiasis, due to the local immunosuppressive effect of glucocorticoids, is a common side effect. Oropharyngeal candidiasis is avoidable to a certain extent by using large volume spacers or rinsing the oropharynx with water after drug delivery. Even when delivered locally, such as by aerosolized inhaler, glucocorticoids may be partly absorbed with consequent systemic side effects due to their high lipid solubility. Particularly notable side effects include suppression of endogenous cortisol synthesis by inhibiting the hypothalamic–pituitary–adrenal axis, particularly at doses higher than 1500 μg/day (Undem and Lichtenstein 2001); the possibility of osteoporosis even at doses of 500 μg/day (Undem and Lichtenstein 2001); a slightly increased risk of glaucoma, particularly during long-term treatment at high doses, and of cataract (Undem and Lichtenstein 2001). Glucocorticoids, particularly at high doses, should be inhaled using a large-volume spacer which increases the profound deposition of the drug and reduces Pharmacological treatment of COPD drug deposition in the oropharynx, with a consequent reduction in the incidence of candidiasis. However, in the absence of proven efﬁcacy and because of possible side effects, including systemic side effects, and high costs, there is no rational pharmacological basis for the use of inhaled glucocorticoids for all patients with stable COPD, and their use should be limited just to the cases previously described (GICOPD 2001). Clinical considerations The choice between β2-agonists, anticholinergic antimuscarinic agents, theophylline or drug combinations depends on individual patient response to the treatment. Pharmacological therapy at each stage of stable COPD according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines is shown in Figure 2 (Figure 2). Bronchodilator combinations may improve drug efﬁcacy and reduce side effects, compared with an increase in the dosage of a single bronchodilator (COMBIVENT 1994). For patients with COPD, long-acting β -agonists 2 delivered by inhalation, such as salmeterol and formoterol, New Characteristics 0: At Risk I: Mild II: Moderate III: Severe IV: Very Severe • Chronic symptoms • Exposure to risk factors • Normal spirometry • FEV1/FVC < 70% • FEV1≥ 80% • With or without symptoms • FEV1/FVC < 70% • 50% ≤ FEV1 < 80% • With or without symptoms • FEV1/FVC < 70% • 30% ≤ FEV1 < 50% • With or without symptoms • FEV1/FVC < 70% • FEV1 < 30% or FEV1 < 50% predicted plus chronic respiratory failure Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments Figure 2 Pharmacological treatment of stable COPD based on GOLD guidelines. Adapted from GICOPD (2001). International Journal of COPD 2006:1(4) 415