Comparison of pneumonia incidence between long-acting muscarinic antagonist and inhaled corticosteroid plus long-acting beta agonist in patients with COPD

Abstract

Few studies have directly compared the incidence of pneumonia in patients on common chronic obstructive pulmonary disease (COPD) treatments such as long-acting muscarinic antagonists (LAMA) with those on inhaled corticosteroids and long-acting β2-agonist (ICS/LABA). Moreover, risk factors for pneumonia in COPD are still unclear. We aimed to compare the incidence of pneumonia in COPD patients on LAMA and those on ICS/LABA and explored the risk factors associated with pneumonia. This nationwide cohort study used Korean National Health Insurance claim data from January 2002 to April 2016. Patients who received COPD medication, either LAMA or ICS/LABA, with the COPD diagnostic code, were selected. We enrolled patients with good compliance (medication possession ratio ≥ 80%). The primary outcome was pneumonia in COPD patients initiating LAMA or ICS/LABA. We investigated the risk factors associated with pneumonia, including the sub-types of ICS treatments. After propensity score matching, the incidence rate per 1000 person-years of pneumonia was 93.96 for LAMA (n = 1003) and 136.42 for ICS/LABA (n = 1003) patients (p < 0.001). The adjusted hazard ratio (HR) for pneumonia in patients on fluticasone/LABA was 1.496 (95% confidence interval [CI] 1.204–1.859) compared with LAMA (p < 0.001). In multivariable analysis, a history of pneumonia was a risk factor associated with pneumonia (HR 2.123; 95% CI 1.580–2.852; p < 0.001). The incidence of pneumonia was higher in COPD patients on ICS/LABA compared with those on LAMA. It is recommended that ICS use be avoided in COPD patients with high pneumonia risk.

Inhaled corticosteroid treatment and pneumonia in patients with chronic obstructive pulmonary disease – nationwide development from 1998 to 2018

“…An important negative side effect of ICS treatment in COPD is the increased risk of pneumonia. Patients with COPD has an increased risk of pneumonia compared to patients without COPD [ 11 ], and ICS treatment further increases this risk [ 12 , 13 ]. This is important because hospitalization with pneumonia is more dangerous than hospitalization with non-pneumonic exacerbation [ 14–16 ].…”

Inhaled Corticosteroids and the Risk of Nontuberculous Mycobacterial Infection in Chronic Airway Disease: A Nationwide Population-Based Study

“…ICS use can potentially cause local (e.g., oral thrush and hoarseness) and systemic (e.g., adrenal suppression and bone density reduction) side effects 7,8 . In particular, prolonged or high-dose use of ICS may suppress the immune system, potentially elevating the risk of infections in the airways and lungs by various pathogens including bacteria, viruses, fungi, and particularly non-tuberculous mycobacteria (NTM) [9][10][11][12][13][14] . NTM, prevalent in the environment, are known to cause significant pulmonary infections, especially in patients with preexisting lung conditions or compromised immune systems 15 .…”