Association between Increased Risk of Pneumonia with ICS in COPD: A Continuous Variable Analysis of Patient Factors from the IMPACT Study

Abstract

Introduction Despite the proven benefits of inhaled corticosteroid (ICS)-containing triple therapy for chronic obstructive pulmonary disease (COPD), clinicians limit patient exposure to ICS due to the risk of pneumonia. However, there are multiple factors associated with the risk of pneumonia in patients with COPD. This post hoc analysis of IMPACT trial data aims to set the risks associated with ICS into a context of specific patient-related factors that contribute to the risk of pneumonia. Methods The 52-week, double-blind IMPACT trial randomized patients with symptomatic COPD and ≥1 exacerbation in the prior year 2:2:1 to once-daily fluticasone furoate (FF)/umeclidinium (UMEC)/vilanterol (VI), FF/VI or UMEC/VI. Annual rate of on-treatment pneumonias in the intent-to-treat population associated with age, body mass index (BMI), percent predicted forced expiratory volume in 1 s (FEV 1 ) and blood eosinophil count (BEC) was evaluated. Results This analysis revealed that the annual rate of pneumonia showed the lowest risk at the age of 50 years. The 95% confidence intervals (CI) between ICS-containing and non-ICS containing treatments diverged in ages > 63 years, suggesting a significantly increased ICS-related risk in older patients. In contrast, the annual rate of pneumonia rose in both groups below BMI of 22.5 kg/m 2 , but above that, there was no relationship to pneumonia rate and no differential effect between the two groups. The relationship between BEC and pneumonia was flat up to > 300/µL cells with ICS-containing treatment and then rose. In contrast, the rate of pneumonia with non-ICS containing treatment appeared to increase at a lower level of BEC (~ 200/µL). Conclusions There was little evidence of a differential effect of older age, lower BMI, lower FEV 1 and BEC on the pneumonia rate between ICS-containing and non-ICS containing treatments. This analysis points to the need for a balanced approach to risk versus benefit in the use of ICS-containing treatments in COPD. Clinical trial registration IMPACT ClinicalTrials.gov number, NCT02164513.

Outcomes among patients with chronic obstructive pulmonary disease after recovery from COVID-19 infection of different severity

“…Almost half of the patients in this cohort were on ICS, and more in the severe COVID-19 group was on ICS than the mild to moderate and non-COVID-19 groups. This could be related to the higher exacerbation number in the past 12 months in the severe COVID-19 group, leading to this possible overuse of ICS in these patients, which might increase their risks of subsequent pneumonia 32 , 33 . We adjusted the use of ICS and other COPD treatments in the multi-variate analysis and showed consistent results, suggesting the effect of severity of COVID-19 to be an independent predictor of the outcomes, including non-COVID respiratory mortality.…”