Inhaled corticosteroids for stable chronic obstructive pulmonary disease

Yang, Ian A.; Fong, Kwun M.; Sim, Esther; Black, Philippa M.; Lasserson, Toby J

doi:10.1002/14651858.cd002991.pub2

Cited by 126 publications

(90 citation statements)

References 145 publications

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“…Similarly, another meta-analysis reported no increase in fractures based on published data from three long-term trials 9. There are also two Cochrane reviews that reported inconclusive findings on the link between ICS and fractures 21 22. Another pooled analysis limited to five published case–control studies which included those with other respiratory conditions such as asthma reported a dose-related increased relative fracture risk of 12% per 1000 μg increase in beclomethasone equivalents 8.…”

Section: Discussionmentioning

confidence: 99%

Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies

Loke

Cavallazzi

Singh³

2011

Thorax

242

139

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BackgroundThe effect of inhaled corticosteroids (ICS) on fracture risk in patients with chronic obstructive pulmonary disease (COPD) remains uncertain. The aim of this study was to evaluate the association between ICS and fractures in COPD. Methods MEDLINE, EMBASE, regulatory documents and company registries were searched up to August 2010. Randomised controlled trials (RCTs) of budesonide or fluticasone versus control treatment for COPD ($24 weeks duration) and controlled observational studies reporting on fracture risk with ICS exposure vs no exposure in COPD were included. Peto OR meta-analysis was used for fracture risk from RCTs while ORs from observational studies were pooled using the fixed effect inverse variance method. Doseeresponse analysis was conducted using varianceweighted least squares regression in the observational studies. Heterogeneity was assessed using the I 2 statistic. Results Sixteen RCTs (14 fluticasone, 2 budesonide) with 17 513 participants, and seven observational studies (n¼69 000 participants) were included in the meta-analysis. ICSs were associated with a significantly increased risk of fractures (Peto OR 1.27; 95% CI 1.01 to 1.58; p¼0.04; I 2 ¼0%) in the RCTs. In the observational studies, ICS exposure was associated with a significantly increased risk of fractures (OR 1.21; 95% CI 1.12 to 1.32; p<0.001; I 2 ¼37%), with each 500 mg increase in beclomethasone dose equivalents associated with a 9% increased risk of fractures, OR 1.09 (95% CI 1.06 to 1.12; p<0.001). Conclusion Among patients with COPD, long-term exposure to fluticasone and budesonide is consistently associated with a modest but statistically significant increased likelihood of fractures. BACKGROUND

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Section: Discussionmentioning

confidence: 99%

Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies

Loke

Cavallazzi

Singh³

2011

Thorax

242

139

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“…76 A Cochrane review of 47 primary studies similarly reported an increased risk of oropharyngeal candidiasis (odds ratio 2.49, 95% CI 1.78 to 3.49) and hoarseness. 77 The TORCH study reported rates per year of candidiasis of 0.7-0.9 with fluticasone-containing treatment compared with 0.2 for salmeterol and placebo groups.…”

Section: Oropharyngeal Candidiasis and Hoarsenessmentioning

confidence: 99%

Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD

Price

Yawn

Brusselle

et al. 2012

Primary Care Respiratory Journal

163

139

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While the pharmacological management of chronic obstructive pulmonary disease (COPD) has evolved from the drugs used to treat asthma, the treatment models are different and the two diseases require clear differential diagnosis in order to determine the correct therapeutic strategy. In contrast to the almost universal requirement for anti-inflammatory treatment of persistent asthma, the efficacy of inhaled corticosteroids (ICS) is less well established in COPD and their role in treatment is limited. There is some evidence of a preventive effect of ICS on exacerbations in patients with COPD, but there is little evidence for an effect on mortality or lung function decline. As a result, treatment guidelines recommend the use of ICS in patients with severe or very severe disease (forced expiratory volume in 1 second <50% predicted) and repeated exacerbations. Patients with frequent exacerbations -a phenotype that is stable over time -are likely to be less common among those with moderate COPD (many of whom are managed in primary care) than in those with more severe disease. The indiscriminate use of ICS in COPD may expose patients to an unnecessary increase in the risk of side-effects such as pneumonia, osteoporosis, diabetes and cataracts, while wasting healthcare spending and potentially diverting attention from other more appropriate forms of management such as pulmonary rehabilitation and maximal bronchodilator use. Physicians should carefully weigh the likely benefits of ICS use against the potential risk of side-effects and costs in individual patients with COPD.

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“…A Cochrane systematic review included 47 randomised placebo-controlled trials (involving a total of 13,139 patients) of inhaled corticosteroids in the treatment of patients with COPD (FEV 1 36–87% of predicted) 16. Long-term (more than 6 months) use of inhaled corticosteroids slightly reduced the rate of exacerbations (undefined in the report) (weighted mean difference −0.26 exacerbations per patient per year, p<0.0001).…”

Section: Preventive Measuresmentioning

confidence: 99%

Preventing exacerbations in COPD

2010

DTB

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Acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality. Patients with frequent exacerbations have high levels of anxiety and depression, significantly impaired health status and faster disease progression. Exacerbations are also the most common cause of emergency respiratory admissions to UK hospitals and are costly to health services. Here we assess whether and how drug and non-drug interventions can help in preventing exacerbations.

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Inhaled corticosteroids for stable chronic obstructive pulmonary disease

Cited by 126 publications

References 145 publications

Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies

Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies

Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD

Preventing exacerbations in COPD

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