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Inhaled corticosteroids and the increased risk of pneumonia: what's new? A 2015 updated review.
Ther Adv Respir Dis. 2016 06; 10(3):235-55.TA

Abstract

There is a considerable amount of evidence that supports the possibility of an increased risk of pneumonia associated with prolonged use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD). However, as yet, no statistically significant increase in pneumonia-related 30-day mortality in patients on ICS has been demonstrated. The lack of objective pneumonia definitions and radiological confirmations have been a major source of bias, because of the similarities in clinical presentation between pneumonia and acute exacerbations of COPD. One of the newer fluticasone furoate studies overcomes these limitations and also provides an assessment of a range of doses, suggesting that the therapeutic window is quite narrow and that conventional dosing has probably been too high, although the absolute risk may be different compared to other drugs. Newer studies were not able to rule out budesonide as responsible for pneumonia, as previous evidence suggested, and there is still need for evidence from head-to-head comparisons in order to better assess possible intra-class differences. Although the exact mechanisms by which ICS increase the risk of pneumonia are not fully understood, the immunosuppressive effects of ICS on the respiratory epithelium and the disruption of the lung microbiome are most likely to be implicated. Given that COPD represents such a complex and heterogeneous disease, attempts are being made to identify clinical phenotypes with clear therapeutic implications, in order to optimize the pharmacological treatment of COPD and avoid the indiscriminate use of ICS. If deemed necessary, gradual withdrawal of ICS appears to be well tolerated. Vaccination against pneumococcus and influenza should be emphasized in patients with COPD receiving ICS. Physicians should keep in mind that signs and symptoms of pneumonia in COPD patients may be initially indistinguishable from those of an exacerbation, and that patients with COPD appear to be at increased risk of developing pneumonia as a complication of ICS therapy.

Authors+Show Affiliations

Hospital de Clínicas 'José de San Martin', Universidad de Buenos Aires, Av. Córdoba 2351, Ciudad de Buenos Aries, C1120AAR, Argentina hiannella@live.com.Hospital de Clínicas 'José de San Martin', Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina.Royal Perth Hospital, University of Western Australia, Western Australia, Australia.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

26893311

Citation

Iannella, Hernan, et al. "Inhaled Corticosteroids and the Increased Risk of Pneumonia: What's New? a 2015 Updated Review." Therapeutic Advances in Respiratory Disease, vol. 10, no. 3, 2016, pp. 235-55.
Iannella H, Luna C, Waterer G. Inhaled corticosteroids and the increased risk of pneumonia: what's new? A 2015 updated review. Ther Adv Respir Dis. 2016;10(3):235-55.
Iannella, H., Luna, C., & Waterer, G. (2016). Inhaled corticosteroids and the increased risk of pneumonia: what's new? A 2015 updated review. Therapeutic Advances in Respiratory Disease, 10(3), 235-55. https://doi.org/10.1177/1753465816630208
Iannella H, Luna C, Waterer G. Inhaled Corticosteroids and the Increased Risk of Pneumonia: What's New? a 2015 Updated Review. Ther Adv Respir Dis. 2016;10(3):235-55. PubMed PMID: 26893311.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Inhaled corticosteroids and the increased risk of pneumonia: what's new? A 2015 updated review. AU - Iannella,Hernan, AU - Luna,Carlos, AU - Waterer,Grant, Y1 - 2016/02/18/ PY - 2016/2/20/entrez PY - 2016/2/20/pubmed PY - 2017/11/9/medline KW - adverse effects KW - chronic obstructive pulmonary disease (COPD) KW - inhaled corticosteroids KW - mortality KW - phenotypes KW - pneumonia SP - 235 EP - 55 JF - Therapeutic advances in respiratory disease JO - Ther Adv Respir Dis VL - 10 IS - 3 N2 - There is a considerable amount of evidence that supports the possibility of an increased risk of pneumonia associated with prolonged use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD). However, as yet, no statistically significant increase in pneumonia-related 30-day mortality in patients on ICS has been demonstrated. The lack of objective pneumonia definitions and radiological confirmations have been a major source of bias, because of the similarities in clinical presentation between pneumonia and acute exacerbations of COPD. One of the newer fluticasone furoate studies overcomes these limitations and also provides an assessment of a range of doses, suggesting that the therapeutic window is quite narrow and that conventional dosing has probably been too high, although the absolute risk may be different compared to other drugs. Newer studies were not able to rule out budesonide as responsible for pneumonia, as previous evidence suggested, and there is still need for evidence from head-to-head comparisons in order to better assess possible intra-class differences. Although the exact mechanisms by which ICS increase the risk of pneumonia are not fully understood, the immunosuppressive effects of ICS on the respiratory epithelium and the disruption of the lung microbiome are most likely to be implicated. Given that COPD represents such a complex and heterogeneous disease, attempts are being made to identify clinical phenotypes with clear therapeutic implications, in order to optimize the pharmacological treatment of COPD and avoid the indiscriminate use of ICS. If deemed necessary, gradual withdrawal of ICS appears to be well tolerated. Vaccination against pneumococcus and influenza should be emphasized in patients with COPD receiving ICS. Physicians should keep in mind that signs and symptoms of pneumonia in COPD patients may be initially indistinguishable from those of an exacerbation, and that patients with COPD appear to be at increased risk of developing pneumonia as a complication of ICS therapy. SN - 1753-4666 UR - https://www.unboundmedicine.com/medline/citation/26893311/Inhaled_corticosteroids_and_the_increased_risk_of_pneumonia:_what's_new_A_2015_updated_review_ L2 - https://journals.sagepub.com/doi/10.1177/1753465816630208?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -