An overview of the benefits and drawbacks of inhaled corticosteroids in chronic obstructive pulmonary disease

Abstract

Background: The benefit harm profile of inhaled corticosteroids, and their effect on patient oriented outcomes and comorbid pneumonia, osteoporosis and cardiovascular disease in patients with chronic obstructive pulmonary disease remain uncertain.

Methods: An overview of the evidence on the risks and benefits of inhaled corticosteroids (fluticasone and budesonide) in chronic obstructive pulmonary disease from recent randomized controlled trials and systematic reviews. Observational studies on adverse effects were also evaluated.

Results: Evidence from recent meta-analysis suggests a modest benefit from inhaled corticosteroid long-acting beta-agonist combination inhalers on the frequency of exacerbations, (rate ratio [RR], 0.82; 95% confidence interval [CI]: 0.78 to 0.88), in improvements in quality of life measures, and forced expiratory volume in one second when compared to long-acting beta-agonists alone. On the outcome of pneumonia, our updated meta-analysis of trials (n = 24 trials; RR, 1.56; 95% CI: 1.40-1.74, P < 0.0001) and observational studies (n = 4 studies; RR, 1.44; 95% CI: 1.20-1.75, P = 0.0001) shows a significant increase in the risk of pneumonia with the inhaled corticosteroids currently available (fluticasone and budesonide). Evidence for any intraclass differences in the risk of pneumonia between currently available formulations is inconclusive due to the absence of head to head trials. Inhaled corticosteroids have no cardiovascular effects.

Conclusions: Among patients with chronic obstructive pulmonary disease, clinicians should carefully balance these long-term risks of inhaled corticosteroid against their symptomatic benefits.

Keywords: cardiovascular events; chronic obstructive pulmonary disease; inhaled corticosteroids; pneumonia.

Figure 1A

Intention to treat meta-analysis of budesonide and the risk of pneumonia in RCTs of COPD (any severity). Abbreviations: COPD, chronic obstructive pulmonary disease; RCT, randomized clinical trial; CI, confidence interval.

Figure 1B

Sensitivity analysis of budesonide and the risk of pneumonia with exclusion of study in mild COPD. Abbreviations: COPD, chronic obstructive pulmonary disease; RCT, randomized clinical trial; CI, confidence interval.

Figure 2

Meta-analysis of inhaled corticosteroids and the risk of pneumonia in observational studies of COPD. Abbreviations: COPD, chronic obstructive pulmonary disease; CI, confidence interval.