Are COPD patients with pneumonia who are taking inhaled corticosteroids at higher risk of dying?

Abstract

In 2007, Calverley et al . [1] reported the results of the TORCH (Towards a Revolution in Chronic Obstructive Pulmonary Disease Health) study, which showed that combination of salmeterol (a long-acting β-agonist (LABA)) plus fluticasone propionate (an inhaled corticosteroid (ICS)) had a trend toward a lower all-cause mortality rate in patients with chronic obstructive pulmonary disease (COPD) compared with the placebo group, with a hazard ratio of 0.825 (95% CI 0.68–1.002; p = 0.052). Despite the beneficial effects of ICS therapy in COPD patients, the results raised a possible safety issue regarding higher rate of community-acquired pneumonia (CAP) in the ICS groups. The probability of having pneumonia was higher among subjects receiving medications containing ICS (19.6% for ICS plus LABA and 18.3% for ICS alone) compared with the placebo group (12.3%; p<0.001) [1]. This association between ICS and pneumonia in COPD patients has also been seen in other studies: one study that examined the potential benefit of ICS and LABAs in reducing COPD mortality [1], and another comparing COPD exacerbation rates between patients receiving either salmeterol or the combination with a LABA [2, 3]. A follow-up evaluation of the TORCH study identified several risk factors associated with pneumonia, including age ≥55 yrs, forced expiratory volume in 1 s <50% predicted, COPD exacerbation in the year prior to the study, worse Medical Research Council dyspnoea score and body mass index <25 kg·m−2. However, mortality rate due to pneumonia was not increased among subjects treated with ICS plus LABA, but the same could not be concluded for ICS monotherapy [4]. Therefore, it was suggested that ICS use increases the risk of CAP in COPD patients; however, the CAP severity event may be milder, and it is possible that these …