Inhaled Steroids Lead to Increased Risk of Pneumonia in Asthma Patients

ICS use associated with 83% increase in rate of pneumonia hospitalization

Asthma patients using the inhaled corticosteroids (ICS) budesonide and fluticasone are at an increased risk of pneumonia, a new study suggests.

The study’s authors were among the first to uncover data in 2007 suggesting that using ICS led to increased pneumonia risk in patients with chronic obstructive pulmonary disease (COPD). However, the risk of pneumonia as related to ICS use in patients with asthma was unclear until now, wrote Pierre Ernst, MD, of McGill University, and colleagues.

“This study shows that the risk for pneumonia, in particular, serious pneumonia leading to hospitalization, in asthma patients is indeed elevated in relation to ICS use. Both budesonide [167% increase in risk] and fluticasone [93% increase in risk] are associated with a statistically significant increase in risk for pneumonia,” the researchers wrote.

While the risk initially appears greater with budesonide than with fluticasone, researchers indicated that confidence intervals overlap such that they could not conclude as to a difference in risk between the two agents.

“Interestingly, while the conclusions of our study are generally consistent with those of previous literature, our study further suggests that budesonide’s risk profile is in fact similar to that of fluticasone,” the report read.

While the overall risk for pneumonia remained low, current ICS use was found to be associated with an increase of 83% in the rate of pneumonia hospitalization. Moreover, higher ICS use was associated with higher risk of pneumonia.

Using non-users as a reference group, the study determined that low dose ICS was associated with a 60% increase in risk of pneumonia, while high dose (dispensing 500µg or more of fluticasone-equivalent per day) was associated with a 96% increase in the risk of pneumonia.

“Pneumonia is a rare adverse effect of inhaled corticosteroids in asthma, while it is quite common in COPD,” Ernst told MD Magazine. “If a patient with asthma develops a severe pneumonia, their physician should assess whether ICS treatment is really necessary.”

The study monitored 152,412 asthma patients between the ages of 12 and 25 in the Canadian Province of Quebec who were prescribed at least one respiratory medication between 1990 and 2007. During that time, nearly 2,000 study subjects were hospitalized for pneumonia, including primary, secondary, admission and death, the study reported.

The study cohort was followed up for an average of 4.8 years, subjects were on average 24.2 years of age at cohort entry and 34.9% were male.

According to the report, further studies are necessary to limit a some outstanding variables.

“For example, in this study, had the data been available, smoking and other environmental exposure would be important variables to consider,” the report read. “Similarly, due to the nature of this study, pneumonia outcomes were identified based on diagnosis codes and not confirmed through further clinical testing. It is therefore possible that these cases of pneumonia are in fact episodes of misdiagnosed asthma exacerbation.”

In future studies, the researchers wrote, it would be helpful to further validate the diagnosis of pneumonia, identify subjects with a confirmed diagnosis of asthma and to adjust for smoking.

You can read the full study as published in the British Journal of Clinical Pharmacology here.