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Published ahead of print on March 30, 2007, doi:10.1164/rccm.200611-1630OC
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American Journal of Respiratory and Critical Care Medicine Vol 176. pp. 162-166, (2007)
© 2007 American Thoracic Society
doi: 10.1164/rccm.200611-1630OC

Original Article

Inhaled Corticosteroid Use in Chronic Obstructive Pulmonary Disease and the Risk of Hospitalization for Pneumonia

Pierre Ernst1, Anne V. Gonzalez1, Paul Brassard1 and Samy Suissa1

1 Pharmacoepidemiology Research Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada

Correspondence and requests for reprints should be addressed to Pierre Ernst, M.D., Division of Clinical Epidemiology, Ross 4.29, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, PQ, H3A 1A1 Canada. E-mail: pierre.ernst{at}mcgill.ca

Rationale: Inhaled corticosteroids are commonly prescribed to patients with chronic obstructive pulmonary disease (COPD).

Objectives: To examine whether these medications might be associated with an excess risk of pneumonia.

Methods: We conducted a nested case-control study within a cohort of patients with COPD from Quebec, Canada, over the period 1988–2003, identified on the basis of administrative databases linking hospitalization and drug-dispensing information. Each subject hospitalized for pneumonia during follow-up (case subjects) was age and time matched to four control subjects. The effect of the use of inhaled corticosteroids was assessed by conditional logistic regression, after adjusting for comorbidity and COPD severity.

Measurements and Main Results: The cohort included 175,906 patients with COPD of whom 23,942 were hospitalized for pneumonia during follow-up, for a rate of 1.9 per 100 per year, and matched to 95,768 control subjects. 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. The rate ratio of hospitalization for pneumonia was greatest with the highest doses of inhaled corticosteroids, equivalent to fluticasone at 1,000 µg/day or more (rate ratio, 2.25; 95% CI, 2.07–2.44). All-cause mortality was similar for patients hospitalized for pneumonia, whether or not they had received inhaled corticosteroids in the recent past (7.4 and 8.2%, respectively).

Conclusions: The use of inhaled corticosteroids is associated with an excess risk of pneumonia hospitalization and of pneumonia hospitalization followed by death within 30 days, among elderly patients with COPD.

Key Words: chronic obstructive pulmonary disease • drug therapy • corticosteroids • inhaled therapy • cohort studies


AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject
A clinical trial has suggested that there may be an excess risk of severe pneumonia in patients using inhaled corticosteroids.

What This Study Adds to the Field
An excess of severe pneumonia requiring hospitalization was seen among patients with chronic obstructive pulmonary disease who were dispensed inhaled corticosteroids. The effect was greatest for those prescribed higher doses in the recent past.

 

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