Abstract
BackgroundInhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. This study assessed the risk of pneumonia associated with ICS in patients with COPD.MethodsElectronic Medical Record data linked to National Health Registries were collected from COPD patients and matched reference controls in 52 Swedish primary care centers (2000–2014). Levels of ICS treatment (high, low, no ICS) and associated comorbidities were assessed. Patients were categorized by airflow limitation severity.ResultsA total of 6623 patients with COPD and 48,566 controls were analyzed. Patients with COPD had a more than 4-fold increase in pneumonia versus reference controls (hazard ratio [HR] 4.76, 95% confidence interval [CI]: 4.48–5.06). ICS use increased the risk of pneumonia by 20–30% in patients with COPD with forced expiratory volume in 1 s ≥ 50% versus patients not using ICS. Asthma was an independent risk factor for pneumonia in the COPD population. Multivariate analysis identified independent predictors of pneumonia in the overall population. The highest risk of pneumonia was associated with high dose ICS (HR 1.41, 95% CI: 1.23–1.62).ConclusionsPatients with COPD have a greater risk of pneumonia versus reference controls; ICS use and concurrent asthma increased the risk of pneumonia further.
Highlights
Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD)
Associations between ICS use and several adverse effects in patients with COPD were first observed in the TORCH (Towards a Revolution in COPD Health) trial, in particular an increased risk of pneumonia [7], which was most apparent in patients with mild-to-moderate airflow limitation
Patient demographics From a total of 55,189 patients listed in electronic medical records (EMRs) with lung function measurements for patients with COPD, 6623 patients with COPD and/or asthma were identified as eligible for inclusion in this study, matched with 48,566 reference controls (Fig. 1)
Summary
Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. International recommendations for the treatment of patients with chronic obstructive pulmonary disease (COPD) restrict the use of inhaled corticosteroids (ICS) containing treatments in patients at high risk of exacerbation (Global initiative for chronic Obstructive Lung Disease [GOLD] Groups C and D) or patients with asthma-COPD overlap (ACO) [1]. Associations between ICS use and several adverse effects in patients with COPD were first observed in the TORCH (Towards a Revolution in COPD Health) trial, in particular an increased risk of pneumonia [7], which was most apparent in patients with mild-to-moderate airflow limitation. An association between use of ICS and pneumonia has been found in observational studies using data from electronic medical records (EMRs) and registries, but these studies have largely lacked spirometry data [15, 16]
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