COPD patients taking inhaled steroids are at greater risk for severe pneumonia

Patients with Chronic Obstructive Pulmonary Disease (COPD) are increasingly being prescribed inhaled corticosteroids to control exacerbations of the disease, but a new study finds that the anti-inflammatory drugs increase the chances that these patients will be hospitalized for pneumonia.

"In a large cohort of patients with COPD, we found that current inhaled corticosteroid use was associated with a significant 70 percent increase in the risk of being hospitalized for pneumonia," said the researchers. "Furthermore, for the severest pneumonias leading to death within 30 days of hospitalization, the risk with current inhaled corticosteroid use was also significantly increased."

These and other findings of the population-based study were reported in the second issue of the July American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

Pierre Ernst, M.D., a clinical epidemiologist at McGill University, Canada, along with three other researchers from the university's department of medicine, analyzed the hospitalization and drug prescription information from 1988 to 2003 of 175,906 patients with COPD living in Quebec, Canada. During that time, 23,942 of the patients were hospitalized for pneumonia.

In their report, the researchers noted that the admission rate for pneumonia increased with higher doses of inhaled steroids and that reduction in risk was observed once the medications were stopped. Among all patients taking inhaled steroids, there was a 53 percent increase in pneumonia deaths within 30 days of being admitted to the hospital.

The investigators noted that these findings are particularly relevant, given that pneumonia is the third leading cause of hospitalization in the United States and that inhaled corticosteroid use among patients with COPD increased from 13.2 to 41.4 percent from 1987 to 1995.

"Adverse effects of inhaled corticosteroids in patients with COPD," the authors said, "are particularly troublesome given the limited evidence for their efficacy."

In an accompanying editorial, Mark Woodhead, D.M, of Manchester (U.K.) Royal Infirmary, wrote that this report confirms secondary findings from a prospective, placebo-controlled study of an inhaled corticosteroid with long-acting , -agonist that was recently published. Given that this earlier study was not designed to analyze pneumonia frequency, its small size and high drop-out rate, he suggested, might lead a reader to reasonably conclude that its , pneumonia findings were spurious."

Now, with the addition of the Canadian population-based study, Dr. Woodhead wrote, the unexpected conclusion--that drugs prescribed to prevent COPD exacerbations put patients at greater risk for severe pneumonia, deserves further consideration and study through large prospective studies with objective pneumonia definitions.

"The finding of an association," he said, "between pneumonia frequency and inhaled corticosteroid use in studies of different design, in different populations, and with evidence of a dose-response relations means that the findings may be real and that these observations cannot simply be dismissed."