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

Abstract

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.

Recurrent pneumonia among Japanese adults: disease burden and risk factors

“…At the same time, we recognize that these drugs consistently decrease COPD exacerbations and improve the quality of life [34, 35] and thus, choices and recommendations regarding the use of inhaled corticosteroids pose a clinical dilemma. These findings suggest that prescribing of inhaled corticosteroids for COPD patients requires special attention when patients have an episode of pneumonia [36]. …”

Initiation of triple therapy maintenance treatment among patients with COPD in the US

“…GOLD criteria advise that triple therapy be initiated in only a specific subgroup of patients, but doctors may not always follow these recommendations. However, overprescribing of triple therapy exposes patients to side effects of ICS, such as pneumonia 5. Additionally, triple therapy places an undue economic burden on patients who may have benefited from other less expensive mono- or dual-COPD medication regimens.…”

Convergence in the Epidemiology and Pathogenesis of COPD and Pneumonia

“…But pneumonia adverse events have also been associated with the use of 160/9 and 320/9 μg/day budesonide/formoterol in 4.7% and 6.4% of COPD patients, respectively (68). As recently stated by Iannella and colleagues, "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" (69).…”