Inhaled Corticosteroids and Risk of Pneumonia

With the advent of medications commonly prescribed for COPD treatment, recent research had focused on the association between patient safety and clinical benefits of these medications when it comes to effective patient care.

During a presentation at CHEST 2014, Marcos Restrepo, MD, FCCP, reviewed the data showing a link between inhaled corticosteroids and the risk of pneumonia. He also discussed the types of inhaled corticosteroids and the dose that is associated most with the development of pneumonia, as well as what impact they may have on clinical outcomes.

While there have always been risk factors associated with pneumonia, the primary problem lies in the fact the need to balance what are the risks of giving this medication versus the benefits of administering the inhaled corticosteroid therapy — whether alone or in combination.

Restrepo commented that everything in this field of study seemed to have been going “fantastic” until the Torch trial surfaced revealing the patients observed in the trial’s probability of pneumonia by 3 years was increased. This undoubtedly spurred an influx of interest, causing researchers to be mindful of the randomized trials within the last 2 years.

A cohort study from Canada divided participants into 2 groups; in the cases in which the subjects had pneumonia and a control with subjects with no pneumonia, there was an increased risk in COPD patients to develop pneumonia.

As the data “exploded,” Restrepo and his team found most of it showed an increased risk, while some showed no difference, and it looked as though there was no reported difference among asthma at that time.

There have been nearly 300 papers published since publications of Restrepo’s summary as well as a meta-analysis almost every week providing a different perspective. It’s interesting to note that most of these studies were not designed to look at specific pneumonia outcome, which is why the numbers tend to be “really small from the beginning”.

Seven years after the initial Torch trial, the initial trials and meta-analyses have shown an increased risk. There is consistently more data suggesting a higher rate of a pneumonic event. Additionally in asthma, most of the trials have suggested that the higher doses have shown a higher risk of pneumonia. One key reason attributed to this is that there is a local immuno-suppressive effect caused by the decrease in the local cellular defense mechanisms particularly in the inhaled corticosteroid in the LABA by reduction of inflammatory cells.

When attempting to clarify whether this was a dose-related event, the Canadian study found that only the higher doses were associated with pneumonia. A new meta-analysis published in Cochrane showcased there are more cases of pneumonia within both groups, though there was no difference in mortality and both groups shared similar withdraw cases.

Restrepo concluded, “Inhaled corticosteroids (ICS) use is associated with a higher risk of developing pneumonia in COPD patients. The class and dose of ICS does not seem to be equal to all ICS with benefits of pneumonia, may be more prevalent for the ICS group.” He added that individualized medicine should be on the forefront of everyone’s minds, “ICS may be associated with better clinical outcomes in patients with CAP and Pleural Effusions, but we are just replying on this observational data.”