Incident Pneumonia and Mortality in COPD Patients - A Double-Effect of Inhaled Corticosteroids?
Am J Respir Crit Care Med. 2014 Nov 19;
Authors: Festic E, Scanlon PD
Abstract
Inhaled corticosteroids are commonly prescribed for patients with severe COPD. Although their use improves quality of life and reduces exacerbations, it is associated with increased risk of pneumonia. Curiously, their use has not been associated with increased risk of pneumonia-related or overall mortality. We review pertinent literature to further explore the effects of inhaled corticosteroids on incident pneumonia and mortality in patients with COPD. The association of use of inhaled corticosteroids and incident pneumonia is substantial, and has been present in the majority of the studies on the topic. This includes both randomized controlled trials as well as observational studies. However, all of the studies have substantial risk of bias. Most randomized trials are limited by lack of systematic ascertainment of pneumonia; they depended on adverse event reporting. Many observational studies included proper radiographic assessment of pneumonia, but they are limited by their retrospective, observational design. The unadjusted higher risk of pneumonia is associated with longer duration of use, more potent ICS compounds, and higher doses. That implies a dose-effect relationship. Unlike pneumonia, mortality is a precise outcome. Despite the robust association of inhaled corticosteroid use with increased risk of pneumonia, all studies find either no difference or a reduction in pulmonary-related and overall mortality associated with the use of inhaled corticosteroids. These observations suggest a double-effect of inhaled corticosteroids, i.e. an adverse effect plus an unexplained mitigating effect.
PMID: 25409118 [PubMed - as supplied by publisher]