Inhaled steroids and risk of pneumonia for chronic obstructive pulmonary disease

Kew, Kayleigh M; Seniukovich, Alieksei

doi:10.1002/14651858.cd010115.pub2

Cited by 320 publications

(332 citation statements)

References 130 publications

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“…A 2014 Cochrane meta-analysis included 43 RCTs of at least 12 week's duration (FP 26 studies, n = 21,247; BUD 17 studies, n = 10,150) to assess the risk of pneumonia with ICS in COPD [Kew and Seniukovich, 2014]. The authors A re-analysis of the data shows a consistently increased risk of pneumonia after removal of the substantial statistical heterogeneity .…”

Section: Meta-analysesmentioning

confidence: 99%

Inhaled corticosteroids and the increased risk of pneumonia: what’s new? A 2015 updated review

Iannella

Luna

Waterer

2016

Ther Adv Respir Dis

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There is a considerable amount of evidence that supports the possibility of an increased risk of pneumonia associated with prolonged use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD). However, as yet, no statistically significant increase in pneumonia-related 30-day mortality in patients on ICS has been demonstrated. The lack of objective pneumonia definitions and radiological confirmations have been a major source of bias, because of the similarities in clinical presentation between pneumonia and acute exacerbations of COPD. One of the newer fluticasone furoate studies overcomes these limitations and also provides an assessment of a range of doses, suggesting that the therapeutic window is quite narrow and that conventional dosing has probably been too high, although the absolute risk may be different compared to other drugs. Newer studies were not able to rule out budesonide as responsible for pneumonia, as previous evidence suggested, and there is still need for evidence from head-to-head comparisons in order to better assess possible intra-class differences. Although the exact mechanisms by which ICS increase the risk of pneumonia are not fully understood, the immunosuppressive effects of ICS on the respiratory epithelium and the disruption of the lung microbiome are most likely to be implicated. Given that COPD represents such a complex and heterogeneous disease, attempts are being made to identify clinical phenotypes with clear therapeutic implications, in order to optimize the pharmacological treatment of COPD and avoid the indiscriminate use of ICS. If deemed necessary, gradual withdrawal of ICS appears to be well tolerated. Vaccination against pneumococcus and influenza should be emphasized in patients with COPD receiving ICS. Physicians should keep in mind that signs and symptoms of pneumonia in COPD patients may be initially indistinguishable from those of an exacerbation, and that patients with COPD appear to be at increased risk of developing pneumonia as a complication of ICS therapy.

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Section: Meta-analysesmentioning

confidence: 99%

Inhaled corticosteroids and the increased risk of pneumonia: what’s new? A 2015 updated review

Iannella

Luna

Waterer

2016

Ther Adv Respir Dis

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“…However, a recent study of a new LABA/ ICS combination containing fluticasone furoate found an excess of eight pneumonia deaths, seven in the group receiving the higher-than-recommended dose of this agent, suggesting that fluticasone itself may be particularly troublesome [24]. However, a recent meta-analysis did not exonerate budesonide [68].…”

Section: Safety Of Ics and Laba/ics In Copdmentioning

confidence: 99%

Inhaled corticosteroids in COPD: the clinical evidence

2014

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In this article, we focus on the scientific evidence from randomised trials supporting treatment with inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD), including treatment with combinations of long-acting β-agonist (LABA) bronchodilators and ICS. Our emphasis is on the methodological strengths and limitations that guide the conclusions that may be drawn.The evidence of benefit of ICS and, therefore, of the LABA/ICS combinations in COPD is limited by major methodological problems. From the data reviewed herein, we conclude that there is no survival benefit independent of the effect of long-acting bronchodilation and no effect on FEV1 decline, and that the possible benefit on reducing severe exacerbations is unclear. Our interpretation of the data is that there are substantial adverse effects from the use of ICS in patients with COPD, most notably severe pneumonia resulting in excess deaths.Currently, the most reliable predictor of response to ICS in COPD is the presence of eosinophilic inflammation in the sputum. There is an urgent need for better markers of benefit and risk that can be tested in randomised trials for use in routine specialist practice. Given the overall safety and effectiveness of long-acting bronchodilators in subjects without an asthma component to their COPD, we believe use of such agents without an associated ICS should be favoured. @ERSpublicationsThe benefits of ICS in COPD are limited. Better tools are needed to identify which patients might benefit.

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“…Interestingly, a systematic review that included 43 randomized clinical trials (over 30,000 patients) found that inhaled corticosteroids increase the risk of pneumonia and hospitalizations in patients with COPD but do not increase the all-cause mortality in these patients. 23 In summary, our study results show that in patients with CAP, those with COPD are sicker as assessed by severity of illness and co-morbidities. Yet these patients do not have worse short-term outcomes.…”

Section: Discussionmentioning

confidence: 56%

The presence of COPD does not influence clinical outcomes in hospitalized patients with community-acquired pneumonia.

Silva¹,

Gearhart²,

Maciel³

et al. 2017

JRI

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Introduction: Community acquired pneumonia (CAP) is a leading cause of death worldwide. Chronic obstructive pulmonary disease (COPD) is a well-established risk factor for development of CAP. What is not as clear is the impact of COPD on the outcomes of patients with CAP. In this study, we compared the outcomes of CAP in COPD and non-COPD patients. Methods: This was a retrospective cohort study. We conducted an analysis of the CommunityAcquired Pneumonia Organization (CAPO) international cohort study database, which includes patients with CAP admitted to several hospitals throughout the world. Patients were categorized into two groups based on the status of COPD: COPD positive or negative. Outcomes were time to clinical stability, length of hospital stay, and in-hospital mortality. Regression models were used to assess the independent effect of COPD on the outcomes. Results: This study included 7,325 patients. Of these, 1,869 (25.5%) had COPD. Patients with COPD had higher severity of illness (pneumonia severity index class V: 15% vs 9%; P <0.001). Accelerated failure time models with adjustment for co-variates showed no significant difference in the probability of clinical stability (P = 0.451) and of discharge (P = 0.232) in COPD vs. non-COPD patients. There was no difference in the crude in-hospital mortality between COPD and non-COPD patients (9% vs 9%; P = 0.37). Conclusion: Our study results show that COPD should not be considered a risk factor for poor outcomes in hospitalized patients with CAP.

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Inhaled steroids and risk of pneumonia for chronic obstructive pulmonary disease

Abstract: Analysis 5.1. Comparison 5 Sensitivity analysis-risk of bias, Outcome 1 Non-fatal serious adverse pneumonia events.

Cited by 320 publications

References 130 publications

Inhaled corticosteroids and the increased risk of pneumonia: what’s new? A 2015 updated review

Inhaled corticosteroids and the increased risk of pneumonia: what’s new? A 2015 updated review

Inhaled corticosteroids in COPD: the clinical evidence

The presence of COPD does not influence clinical outcomes in hospitalized patients with community-acquired pneumonia.

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