Risk was not elevated in patients who received budesonide.
Do inhaled corticosteroids elevate risk for pneumonia in patients with chronic obstructive pulmonary disease? Several clinical trials, observational studies, and meta-analyses suggest that they do, by as much as 70%. But, in other trials, researchers have reported lower risk, and previous meta-analyses have been criticized for methodological weaknesses, such as combining trials of inhaled budesonide with those of fluticasone.
Canadian researchers pooled patient-level data from seven large clinical trials in which more than 7000 patients with COPD were randomized to inhaled budesonide or placebo, with or without the long-acting β2-agonist formoterol, for 6 to 12 months. In both groups, 3% of patients developed pneumonia; in 1% of budesonide recipients and in 2% of placebo recipients, it was a serious adverse event (i.e., causing hospitalization or death), with no significant difference between groups, before or after adjustment for potential confounders.
Comment: Budesonide is cleared more rapidly from the airways than fluticasone, and the authors speculate that this fact could help explain why pneumonia risk is not elevated with budesonide (as it seems to be with fluticasone). Surprisingly, despite high mortality associated with community-acquired pneumonia, no study has shown that fatal pneumonia is more common among patients who receive inhaled steroids, which suggests that pneumonias induced by inhaled steroids are relatively mild. An editorialist concludes that the benefits of inhaled steroids in COPD patients continue to outweigh the risks substantially.
Bruce Soloway, MD
Published in Journal Watch General Medicine September 8, 2009
- Sin DD et al. Budesonide and the risk of pneumonia: A meta-analysis of individual patient data. Lancet 2009 Aug 29; 374:712.
- Welte T. Inhaled corticosteroids in COPD and the risk of pneumonia. Lancet 2009 Aug 29; 374:668.