Do inhaled steroids for COPD cause pneumonia, or cure it? Or both? The effects of inhaled corticosteroid use on pneumonia and mortality in people with COPD has been an area of simmering debate, ever since the TORCH trial. Using a wealth of observational data from VA databases, Chen et al add a key piece to the puzzle.
They retrospectively examined 15,768 vets with a diagnosis of COPD who were hospitalized for pneumonia, about half of whom were using ICS chronically. Looking at the raw data, those prescribed inhaled steroids had a lower 90-day mortality after pneumonia (17% vs. 23%, p<.001). In regression analyses (controlling for severity of COPD, among many other factors), inhaled corticosteroids still appeared to have a protective effect in pneumonia with COPD:
- 30-day mortality odds ratio 0.80 (0.72-0.89)
- 90-day mortality odds ratio 0.78 (0.72-0.85)
- Need for mechanical ventilation odds ratio 0.83 (0.72-0.94)
The weight of several studies suggests that taking ICS for COPD increases the risk for pneumonia. But studies using “harder” clinical outcomes as endpoints have been conflicting, with a minority suggesting increased pneumonia-related mortality, but most (along with meta-analyses) suggesting no impact of ICS on either pneumonia-related or all-cause mortality in COPD.
For the moment, let’s accept that inhaled corticosteroids cause pneumonia in some people with COPD, but reduce the severity and lethality of any pneumonia. A few people die from ICS-related pneumonia, and others with ICS-unrelated pneumonia are protected and survive, due their preceding use of ICS. The question is:
Do ICS prevent more deaths from “random” (non-ICS-associated) pneumonias than the deaths they cause through “iatrogenic” ICS-related pneumonia?
TORCH seems to have helped answer this (since the pneumonia rate was higher, but mortality trended lower in the ICS group, the pneumonias could not have been excessively lethal). That said, steroid-treated patients in TORCH had an absolute 6% increased risk for pneumonia (administratively, not clinically confirmed). I haven’t yet looked at the rates of ICS-attributable pneumonia in the meta-analyses.
Inhaled steroids’ benefits (preventing exacerbations, improving dyspnea / quality-of-life) are felt to outweigh their risks. As you know, 2010 GOLD recommendations are that inhaled corticosteroids be prescribed to symptomatic patients with FEV1 < 50% who also have frequent exacerbations. AJRCCM 2011;184:312-316.