Inhaled Steroids Linked to Pneumonia Hospitalizations in COPD

MONTREAL, July 16 -- Chronic obstructive pulmonary disease patients who inhaled corticosteroids had a 70% increase in the risk of pneumonia hospitalization over those not given the drugs, researchers here reported.

In a nested case-control study, the risk of dying within 30 days of hospitalization for pneumonia was 53% higher for COPD patients who inhaled corticosteroids, Pierre Ernst, M.D., of Royal Victoria Hospital, and colleagues, reported in the July 15 issue of the American Journal of Respiratory and Critical Care Medicine.

Moreover, there was a dose-dependent relationship between risk of pneumonia and corticosteroid use so that patients inhaling doses equivalent to at least 1,000 g/day of fluticasone had a 2.25 rate ratio for pneumonia hospitalization (95% CI 2.02-2.44), they wrote.

The study was conducted within a cohort of 175, 906 COPD patients from the province of Quebec who were treated from 1988 through 2003, including 23,942 who were hospitalized for pneumonia and 95,768 matched controls.

Half of the patients were men and the average age was 77. Mean follow-up was a little more than seven years.

Among the findings:

• COPD patients were hospitalized for pneumonia at a rate of 1.9 per 100 per year.
• All cause mortality was for patients who used steroids and were hospitalized for pneumonia was 7.4% versus 8.4% all cause mortality for COPD patients who were hospitalized for pneumonia but didn't use steroids.
• Almost half of the COPD patients hospitalized for pneumonia (48.2%) had used inhaled corticosteroids in the previous year versus 30.1% of controls.
• Past use of corticosteroids was associated with only a slight increase in risk of hospitalization for pneumonia, 20% for corticosteroids dispensed nine to 12 months prior.

The adjusted rate ratio of hospitalization for pneumonia associated with current use of inhaled corticosteroids was 1.70 (95% confidence interval [CI], 1.63-1.77) and 1.53 (95% CI, 1.30-1.80) for pneumonia hospitalization followed by death within 30 days.

In an editorial Mark Woodhead, D.M., of Manchester Royal Infirmary in Manchester, England noted that the findings of this study confirm an earlier randomized trial that found corticosteroids reduced COPD exacerbations, but the price was an increase in hospitalizations for pneumonia.

Similar findings from studies using different designs suggest that link between corticosteroids and pneumonia may be "real and that these observations cannot simply be dismissed."

Dr. Ernst and colleagues wrote that COPD is a risk factor for pneumonia and higher doses of inhaled corticosteroids may be a marker of more severe disease, which may have contributed to the observed dose-dependent relationship between inhaled corticosteroids and pneumonia hospitalizations.

But they said that differences in severity of disease were accounted for by factoring in the number of prescriptions for COPD medications used by both cases and controls.

A strength of the study was the large number of pneumonia hospitalizations, "thus allowing precise estimates of risk associated with various doses of inhaled corticosteroids."