Inhaled Corticosteroids in Patients With Stable Chronic Obstructive Pulmonary Disease

Abstract

Context Recent studies of inhaled corticosteroid (ICS) therapy for managing stable chronic obstructive pulmonary disease (COPD) have yielded conflicting results regarding survival and risk of adverse events. Objective To systematically review and quantitatively synthesize the effects of ICS therapy on mortality and adverse events in patients with stable COPD. Data Sources Search of MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PsychInfo through February 9, 2008. Study Selection Eligible studies were double-blind, randomized controlled trials comparing ICS therapy for 6 or more months with nonsteroid inhaled therapy in patients with COPD. Data Extraction Two authors independently abstracted data including study characteristics, all-cause mortality, pneumonia, and bone fractures. The I2 statistic was used to assess heterogeneity. Study-level data were pooled using a random-effects model (when I2≥50%) or a fixed-effects model (when I2<50%). For the primary outcome of all-cause mortality at 1 year, our meta-analysis was powered to detect a 1.0% absolute difference in mortality, assuming a 2-sided α of .05 and power of 0.80. Results Eleven eligible randomized controlled trials (14 426 participants) were included. In trials with mortality data, no difference was observed in 1-year all-cause mortality (128 deaths among 4636 patients in the treatment group and 148 deaths among 4597 patients in the control group; relative risk [RR], 0.86; 95% confidence interval [CI], 0.68–1.09; P=.20; I2=0%). In the trials with data on pneumonia, ICS therapy was associated with a significantly higher incidence of pneumonia (777 cases among 5405 patients in the treatment group and 561 cases among 5371 patients in the control group; RR, 1.34; 95% CI, 1.03–1.75; P=.03; I2=72%). Subgroup analyses indicated an increased risk of pneumonia in the following subgroups: highest ICS dose (RR, 1.46; 95% CI, 1.10–1.92; P=.008; I2=78%), shorter duration of ICS use (RR, 2.12; 95% CI, 1.47–3.05; P<.001; I2=0%), lowest baseline forced expiratory volume in the first second of expiration (RR, 1.90; 95% CI, 1.26–2.85; P=.002; I2=0%), and combined ICS and bronchodilator therapy (RR, 1.57; 95% CI, 1.35–1.82; P<.001; I2=24%). Conclusions Among patients with COPD, ICS therapy does not affect 1-year all-cause mortality. ICS therapy is associated with a higher risk of pneumonia. Future studies should determine whether specific subsets of patients with COPD benefit from ICS therapy.

Inhaled Corticosteroids Do Not Influence the Early Inflammatory Response and Clinical Presentation of Hospitalized Subjects With COPD Exacerbation

“…Although the use of inhaled corticosteroids in COPD patients has been demonstrated to be useful in the reduction of exacerbation events 16,17 and in protection against the development of complicated forms of hospitalized community-acquired pneumonia. 14,15 On the other hand, the long-term use of inhaled corticosteroids increases the risk of pneumonia, [18][19][20] especially with fluticasone. 20 Our study, performed in subjects with COPD exacerbation but without pneumonia, demonstrates that inhaled corticosteroids have no detrimental effect on the development of complications on admission or in other outcomes collected during the clinical course.…”

“…18,19 Moreover, another large study followed stable COPD subjects for a period of 5 y and showed that the risk of severe pneumonia was strictly dose-related to exposure of inhaled corticosteroids and was higher in patients who had used fluticasone in comparison with budesonide. 20 We hypothesized that chronic domiciliary treatment with inhaled corticosteroids would influence the early systemic inflammatory response of COPD exacerbation and have an impact on clinical presentation and patient outcome.…”

Difficulties in differential diagnosis of COPD and asthma in primary care

“…The diagnostic accuracy of asthma and COPD diagnoses were tested using two differential diagnosis questionnaires. meta-analysis 14 concluded that the use of ICs in patients with stable COPD does not reduce mortality and significantly increases the incidence of pneumonia. Conversely, the use of long-acting beta agonists (LABAs) as monotherapy for asthma is not recommended for safety reasons.…”

Antibiotic Resistance in Nursing Homes

“…Some of these medications may increase the likelihood of infections: atypical antipsychotics may impair consciousness and increase the frequency of aspiration (Knol W & Al, 2008;Gau JT & Al, 2010); H2 blockers and protonic pump inhibitors (PPI) lead to decreased gastric acidity and may contribute to increased gastrointestinal infections (Laheij RI & Al;2004;Gulmez SE & Al, 2007;Eom CS & Al 2011;Laria A & Al, 2011). Oral and inhaled glucocorticoid therapy are associated with an increased dose-dependent risk of infections (Ernst P & Al, 2007;Calverley PM & Al, 2007;Kardos P & Al, 2007;Drummond MB & Al, 2008;Singh S & Al, 2009;Smitten AL, & Al 2008;Dixon WG & Al, 2011).…”