Inhaled corticosteroids in COPD and the risk of serious pneumonia

Suissa, Samy; Patenaude, Valérie; Lapi, Francesco; Ernst, Pierre

doi:10.1136/thoraxjnl-2012-202872

Cited by 405 publications

(362 citation statements)

References 32 publications

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“…Although significant risk was seen with both fluticasone and budesonide, the rate ratio was higher with fluticasone (RR 2.01; 95 % CI 1.93-2.10) than with budesonide (RR 1.17; 95 % CI 1.09-1.26). The dose-response effect was particularly evident in the fluticasone group, where the risk of serious pneumonia increased from 46 % with a low dose to 122 % with a high dose [61]. Recent evidence from the PATHOS (An Investigation of the Past 10 Years Health Care for Primary Care Patients with Chronic Obstructive Pulmonary Disease) study appear to confirm the safety profile of budesonide in the COPD population [62].…”

Section: Pneumoniamentioning

confidence: 90%

“…The lack of long-term head-to-head trials comparing fluticasone propionate, budesonide, and mometasone limited the possibility to find potential differences between these ICSs. In this regard, Suissa and coworkers [61] conducted a population-based cohort study of treated patients with COPD to assess whether the different ICSs vary in their risk of pneumonia. Although significant risk was seen with both fluticasone and budesonide, the rate ratio was higher with fluticasone (RR 2.01; 95 % CI 1.93-2.10) than with budesonide (RR 1.17; 95 % CI 1.09-1.26).…”

Section: Pneumoniamentioning

confidence: 99%

“…In this regard, it has been demonstrated that gargling and mouth rinsing with about 20 ml water for 5 seconds three times is sufficient to remove both the residual dry powder and aerosol-type ICS from the mouth [80]. The dose-response effect observed with ICSs with the incidence of serious pneumonia [61] has important practical considerations for elderly patients at high risk. In this respect, the use of the lowest effective dose of ICS, if any, is mandatory in the long-term management of stable COPD.…”

Section: Practical Considerations For Elderly Patients On Long-term Dmentioning

confidence: 99%

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Erratum to: Safety Considerations of Inhaled Corticosteroids in the Elderly

et al. 2015

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Inhaled corticosteroids (ICSs) are widely used in the treatment of patients with chronic obstructive pulmonary diseases. However, high-dose regimens and longterm use of ICSs have the potential to cause a variety of local and systemic side effects such as candidiasis, cataracts, glaucoma, and osteoporosis. The use of ICSs can also be associated with the risk of bone fractures, diabetes mellitus and pneumonia. These ICS-related side effects are of particular importance in elderly patients due to the presence of comorbidities and age-related behavioral, cognitive, and psychological problems, which can all interact with inhaled treatment. We reviewed the available literature on the clinically relevant side effects of ICSs in the elderly to provide practical measures to properly monitor and manage the risk of ICSs in the geriatric population. Inspection of the mouth, monitoring of ocular pressure, and use of bone-protective drugs may be necessary in patients on prolonged ICS therapy. Above all, the use of the lowest possible ICS dose and a careful re-assessment of the inhalation procedure should be recommended. Taken together, these observations suggest that physicians should use ICSs appropriately for those patients in whom the benefit will outweigh the risk, especially chronic obstructive pulmonary disease (COPD) patients with previous frequent exacerbations. Given the paucity of information on the topic and the need to extrapolate the results from studies with broader age ranges, we strongly encourage the design of specifically tailored clinical studies in the elderly. Key PointsAsthma and chronic obstructive pulmonary disease (COPD) are inflammatory disorders of the airways. The pharmacological management of these chronic diseases is based on persistent and long-term use of inhaled corticosteroids (ICSs).Asthma and COPD are among the most common chronic diseases in clinical settings, and physicians are expected to diagnose and manage those diseases in the geriatric population on a daily basis. The management of chronic obstructive respiratory diseases in the geriatric population is complicated by the increased occurrence of comorbidities and associated treatment, and by age-associated physiological and structural changes of the lung.The chronic use of ICSs in the elderly is associated with the increased risk of local and systemic side effects such as candidiasis, cataract, glaucoma, diabetes mellitus, bone fractures, and pneumonia. Physicians should be aware of this in order to select those patients in whom the benefits will outweigh the risks.The online version of the original article can be found under

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Section: Pneumoniamentioning

confidence: 90%

Section: Pneumoniamentioning

confidence: 99%

Section: Practical Considerations For Elderly Patients On Long-term Dmentioning

confidence: 99%

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Erratum to: Safety Considerations of Inhaled Corticosteroids in the Elderly

et al. 2015

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“…152 More recently, considering the potential for ICS side effects (pneumonia, cataract, osteoporosis, etc.) that have been demonstrated in many RCTs 152,153 and administrative database studies, 154 step down ICS or stepwise ICS withdrawal has been proposed in COPD patients on ICS treatment. In one recent large trial, patients with COPD receiving combined inhaled treatment with a LAMA plus ICS/LABA who underwent stepwise ICS withdrawal did not experience significantly increased exacerbation rates.…”

Section: Summary Of Evidencementioning

confidence: 99%

CTS position statement: Pharmacotherapy in patients with COPD—An update

Bourbeau

Bhutani

Hernández

et al. 2017

Canadian Journal of Respiratory, Critical Care, and Sleep Medic

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RATIONALE: Since the last published Canadian Thoracic Society (CTS) COPD guideline in 2007 and the 2008 update -highlights for primary care, many new clinical trials have challenged COPD treatment practices. The current Canadian position statement provides the reader with an update on pharmacotherapy of patients with COPD as reviewed by the CTS. OBJECTIVES: The objectives of this position statement are: 1) to summarize the literature on topics relevant to the pharmacological therapy of patients with stable COPD; and 2) to provide clinical guidance with evidence-based recommendations and expert-informed key messages for the pharmacological therapy for patients with stable COPD. METHODS: The authors systematically reviewed the relevant literature focusing on randomized controlled trials and when available, systematic reviews of randomized controlled trials. The proposed key messages, based on scientific evidence and expert-informed opinion, were agreed upon by a majority consensus. MAIN RESULTS: There is typically a significant delay in seeking medical care by patients with dyspnea, often waiting until symptoms affect the performance of activities of daily living. The diagnosis of COPD requires spirometry to confirm the presence of airflow obstruction in any patient presenting with symptoms and/or risk factors of COPD. An effective management plan for individuals with COPD should include: smoking cessation, vaccination and education. A number of non-pharmacological treatments are available for COPD patients with symptoms to improve outcomes such as self-management with coaching from a health care professional; pulmonary rehabilitation; supplemental oxygen in selected patients; and surgery.Current pharmacotherapy for COPD has been shown to alleviate symptoms and prevent exacerbations and related complications such as hospital admissions. In symptomatic patients with stable COPD not having or having infrequent exacerbation, treatment should be started with inhaled LAMA or LABA monotherapy, and if experiencing persistent or increased dyspnea, exercise intolerance, and/or reduced health status despite use of monotherapy, patients should be considered for treatment "step up" with an inhaled LAMA plus LABA dual therapy. In this situation, the use of a single inhaler would be preferred to simplify the treatment regimen and minimize the cost. In patients with stable COPD experiencing exacerbations despite the use of LAMA or LABA monotherapy, treatment "step up" with inhaled LAMA plus LABA dual therapy should be considered unless a patient has concomitant asthma (Asthma/COPD overlap (ACO)). There has been recent interest in using biomarkers to identify patients who are more likely to respond to ICS. Most of the studies have demonstrated that high blood eosinophils could be valuable to predict an increase response in terms of reduction of exacerbation rate when treated with combination ICS/LABA; there is still uncertainty about the exact cut-off level of blood eosinophils having potential therapeutic value. If a pa...

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“…Nonetheless, already the first edition of the GOLD strategy paper of 2001 stated that ICS in COPD should only be used together with regular bronchodilators, and be restricted to patients with poor lung function and a history of repeated exacerbations [3]. Contrary to this recommendation, ICS/LABA products have since then been massively (over-) prescribed for COPD subjects with low or absent risk of exacerbations [4], overestimating the clinical benefits of ICS in this population, and, importantly, underestimating risk associated with long-term use of higher ICS doses in COPD, in particular increased pneumonia rates [5]. Although ever since there have been countless review papers, workshops and conferences about ''who needs ICS in COPD'', it appeared that the overuse of ICS in COPD was indeed a hard habit to break.…”

mentioning

confidence: 99%

And Then There Were Three: Time to Move Onward in COPD Drug Development Beyond LAMA/LABA/ICS at Last?

Beeh

2018

Pulm Ther

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Inhaled corticosteroids in COPD and the risk of serious pneumonia

Cited by 405 publications

References 32 publications

Erratum to: Safety Considerations of Inhaled Corticosteroids in the Elderly

Erratum to: Safety Considerations of Inhaled Corticosteroids in the Elderly

CTS position statement: Pharmacotherapy in patients with COPD—An update

And Then There Were Three: Time to Move Onward in COPD Drug Development Beyond LAMA/LABA/ICS at Last?

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