Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

COPD, pneumonia and inhaled corticosteroids

The American Journal of Respiratory and Critical Care Medicine has published the results of a study that examined the risk of pneumonia in elderly patients using inhaled corticosteroids (ICS) for chronic obstructive pulmonary disease (COPD).

This study was a retrospective cohort study with case control analysis conducted using health databases in Quebec, Canada. It was prompted by the recent finding in the TORCH Study, a randomised controlled study that identified a possible link between ICS and pneumonia.

This analysis found that use of ICS:

  • Increased the risk of pneumonia, RR 1.70 [95% CI 1.63-1.77]
  • Increased the risk of death within 30 days following pneumonia related admission, RR 1.53 [95% CI 1.30-1.80]
  • At higher doses (equivalent to 1,000micrograms fluticasone) was associated with a higher risk of pneumonia 2.25 [95% CI 2.07-2.44]

The authors conclude that there is an increased risk of hospital admission for pneumonia, and of death following this, for patients with COPD using inhaled corticosteroids. They advise that this risk needs to be considered when prescribing.

Meanwhile, an accompanying editorial points out that COPD is associated with an increased risk of pneumonia and also identifies several flaws in this new analysis including the criteria used for diagnosis of pneumonia, COPD and categorisation of severity of COPD.

The author of the editorial concludes that, "these observations cannot simply be dismissed" however he also calls for further large studies to be conducted which make use of objective pneumonia definitions.

Action: Using ICS in COPD (in combination with long acting bronchodilators) appears to reduce exacerbations. Additional work is required to allow a fuller understanding of the risks and benefits of ICS use in COPD. In the meantime clinicians should continue to implement the NICE Guideline on COPD.

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