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Objectives: To conduct a systematic review and meta-analysis regarding the efficacy and safety of inhaled corticosteroids for COPD exacerbations(eg, exacerbations associated with smoking).

Methods: Searches of MEDLINE (1966–January 2013), TISSI (1980–January 2013), The Cochrane Library (1980–January 2013), EMBASE (1980–January 2013), Embase (1980–January 2013), CINAHL (1980–1981), and Web of Science from inception through December 31, 2013 using the terms "COPD [including both] exacerbations," "COPD exacerbations," "smoking bronchitis," and "tobacco use disorders [including both]" were conducted. Searches were limited by the term "COPD exacerbations." Random-effects meta-analyses of randomised controlled trials (RCTs) with the following parameters were used to assess the effects of various inhaled corticosteroidal doses, dosages, routes and schedules across four categories (COPD exacerbations, smoking, non-smoking, and use of non-smokers) of patients: COPD exacerbations associated with smoking, COPD exacerbations not associated with smoking, non-smoking exacerbations, and use of non-smokers. Effect sizes for the pooled estimates of the RCTs for each bronchodilator dosage and combination and of each bronchodilator category and dosage group were then estimated. The effect sizes for all RCTs were reported, and 95% CIs for effect sizes and 95% confidence intervals were calculated.

Results: The search identified 22 eligible studies of 11 RCTs. Of these 22, two included nonsmokers (one with a smoking-induced exacerbation), two included smokers (one with a non-smoking exacerbation), and ten included people who did not use any bronchodilators (non-smoking exacerbations and non-smoking exacerbations with or without COPD) (four studies; one study with data on both tobacco use and COPD exacerbations, four studies with data on both factors, and one study with information on only non-smokers). Of the 22 eligible studies, 10 (60%) were cohort studies, 14 (37%) were cross-sectional studies, and one (3%) was a case-control study (one study; 16 deaths). Forty‐eight RCTs met inclusion criteria. The overall weighted mean effect size (SMD) was −1.05 (−0.93–0.19). The SMD was not significantly less than zero and ranged from −0.25 to 0.

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