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Giraldo-Cadavid LF, Insignares D, Velasco V, Londoño N, Galvis AM, Rengifo ML, Bastidas-Goyes AR. Fiberoptic Endoscopy Evaluation of Swallowing (FEES) Findings Associated with High Pneumonia Risk in a Cohort of Patients at Risk of Dysphagia. Dysphagia 2024:10.1007/s00455-024-10727-w. [PMID: 38958706 DOI: 10.1007/s00455-024-10727-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 05/23/2024] [Indexed: 07/04/2024]
Abstract
Aspiration detected in the fiberoptic endoscopy evaluation of swallowing (FEES) has been inconsistently associated with pneumonia, with no evidence of the risk of pneumonia from other alterations in swallowing safety detected in FEES. We conducted a dynamic, ambidirectional cohort study involving 148 subjects at risk of dysphagia in a tertiary university hospital. Our aim was to determine the risk of pneumonia attributed to alterations in swallowing safety detected during FEES. We used multivariate negative binomial regression models to adjust for potential confounders. The incidence density rate (IR) of pneumonia in patients with tracheal aspiration of any consistency was 26.6/100 people-years (RR 7.25; 95% CI: 3.50-14.98; P < 0.001). The IR was 19.7/100 people-years (RR 7.85; 95% CI: 3.34-18.47; P < 0.001) in those with laryngeal penetration of any consistency and 18.1/100 people-years (RR 6.24; 95% CI: 2.58-15.09; P < 0.001) in those with pharyngeal residue of any consistency. When adjusted for aspiration, the association of residue and penetration with pneumonia disappeared, suggesting that their risk of pneumonia is dependent on the presence of aspiration and that only aspiration is independently associated with pneumonia. This increased risk of pneumonia was significant in uni- and multivariate negative binomial regression models. We found an independently increased risk of pneumonia among patients with dysphagia and aspiration detected during FEES. Alterations in the oral and pharyngeal phases of swallowing, without aspiration, did not increase the risk of pneumonia.
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Affiliation(s)
- Luis F Giraldo-Cadavid
- Department of Epidemiology and Biostatistics, Facultad de Medicina de la Universidad de La Sabana, Chia, Cundinamarca, Colombia.
- Interventional Pulmonology Division, Fundación Neumológica Colombiana, Bogotá DC, Colombia.
- Departments of Internal Medicine and Pulmonary Medicine, Facultad de Medicina de la Universidad de La Sabana, Campus Puente del Común, Autopista norte de Bogotá Km 7, Chía, Cundinamarca, Colombia.
| | - Diego Insignares
- Interventional Pulmonology Division, Fundación Neumológica Colombiana, Bogotá DC, Colombia
- Departments of Internal Medicine and Pulmonary Medicine, Facultad de Medicina de la Universidad de La Sabana, Campus Puente del Común, Autopista norte de Bogotá Km 7, Chía, Cundinamarca, Colombia
| | - Valentina Velasco
- Department of Rehabilitation Medicine, Facultad de Medicina de la Universidad de La Sabana and Clínica Universidad de La Sabana, Chía, Colombia
| | - Natalia Londoño
- Department of Epidemiology and Biostatistics, Facultad de Medicina de la Universidad de La Sabana, Chia, Cundinamarca, Colombia
| | - Ana María Galvis
- Department of Rehabilitation Medicine, Clínica Universidad de La Sabana, Chía, Colombia
| | - María Leonor Rengifo
- Department of Rehabilitation Medicine, Facultad de Medicina de la Universidad de La Sabana and Clínica Universidad de La Sabana, Chía, Colombia
| | - Alirio R Bastidas-Goyes
- Department of Epidemiology and Biostatistics, Facultad de Medicina de la Universidad de La Sabana, Chia, Cundinamarca, Colombia
- Departments of Internal Medicine and Pulmonary Medicine, Facultad de Medicina de la Universidad de La Sabana, Campus Puente del Común, Autopista norte de Bogotá Km 7, Chía, Cundinamarca, Colombia
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Basille D, Wang L, Thomsen RW, Menon J, Shetty N, Duhaut P, Andrejak C, Jounieaux V, Sørensen HT. Inhaled corticosteroids and adverse outcomes among chronic obstructive pulmonary disease patients with community-acquired pneumonia: a population-based cohort study. Front Med (Lausanne) 2023; 10:1184888. [PMID: 37554496 PMCID: PMC10405521 DOI: 10.3389/fmed.2023.1184888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/10/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION While inhaled corticosteroids (ICS) may increase pneumonia risk in patients with chronic obstructive pulmonary disease (COPD), the impact of ICS on pneumonia outcomes is debated. We examined whether ICS use is associated with adverse outcomes among COPD patients with community-acquired pneumonia (CAP). MATERIALS AND METHODS Population-based cohort study of all COPD patients with an incident hospitalization for CAP between 1997 and 2013 in Northern Denmark. Information on medications, COPD severity, comorbidities, complications, and death was obtained from medical databases. Adjusted risk ratios (aRRs) for pleuropulmonary complications, intensive care unit (ICU) admissions, and 30-day mortality in current and former ICS users were compared with those in non-users, using regression analyzes to handle confounding. RESULTS Of 11,368 COPD patients with CAP, 6,073 (53.4%) were current ICS users and 1,733 (15.2%) were former users. Current users had a non-significantly decreased risk of pleuropulmonary complications [2.6%; aRR = 0.82 (0.59-1.12)] compared to non-users (3.2%). This was also observed among former users [2.5%; aRR = 0.77 (0.53-1.12)]. Similarly, decreased risks of ICU admission were observed among current users [aRR = 0.77 (0.57-1.04)] and among former users [aRR = 0.81 (0.58-1.13)]. Current ICS users had significantly decreased 30-day mortality [9.1%; aRR = 0.72 (0.62-0.85)] compared to non-users (12.6%), with a stronger association observed among patients with frequent exacerbations [0.58 (0.39-0.86)]. No significant association was observed among former ICS users [0.89 (0.75-1.05)]. CONCLUSION Our results suggest a decreased risk of death with ICS use among COPD patients admitted for CAP.
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Affiliation(s)
- Damien Basille
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France
- AGIR Unit–UR4294, University Picardie Jules Verne, Amiens, France
- RECIF Unit, University Picardie Jules Verne, Amiens, France
| | - Lei Wang
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jyothi Menon
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Nisha Shetty
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Pierre Duhaut
- RECIF Unit, University Picardie Jules Verne, Amiens, France
- Department of Internal Medicine, University Hospital Centre Amiens-Picardie, Amiens, France
| | - Claire Andrejak
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France
- AGIR Unit–UR4294, University Picardie Jules Verne, Amiens, France
- RECIF Unit, University Picardie Jules Verne, Amiens, France
| | - Vincent Jounieaux
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France
- AGIR Unit–UR4294, University Picardie Jules Verne, Amiens, France
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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Design of the Reducing Diagnostic Error to Improve Patient Safety (REDEfINE) in COPD and asthma study: A cluster randomized comparative effectiveness trial. Contemp Clin Trials 2022; 123:106971. [PMID: 36280032 DOI: 10.1016/j.cct.2022.106971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 01/27/2023]
Abstract
Although spirometry is a simple, portable test and recommended for the diagnosis of asthma and chronic obstructive pulmonary disease (COPD), it is not routinely used in the primary care setting. Minorities and underserved populations are less likely to have spirometry assessment, leading to both over and misdiagnosis of asthma and COPD. Because dyspnea is a common symptom across multiple diseases, use of spirometry as a diagnostic tool is important. Missed, delayed, or misdiagnosis of asthma and COPD, which are considered diagnostic errors (DE), can lead to poor quality of care, increased morbidity and mortality, and increased costs to patients and health systems. Barriers to the use of spirometry have been identified at clinician/clinic and health systems levels. The REDEFINE program is designed to overcome identified barriers to spirometry use in primary care by utilizing health promoters (HPs) who perform spirometry within primary care clinics and work collaboratively with clinicians to incorporate the results at the point of care without interrupting clinic workflow. The REDEFINE trial is a comparative effectiveness study comparing outcomes of the REDEFINE program with usual care (UC) in primary care patients determined to be at increased risk of DE for asthma and COPD. The primary outcome will be all-cause hospitalizations. The secondary outcomes will be the proportion of accurate diagnosis of COPD, asthma, or asthma-COPD overlap based on initial diagnosis and spirometry and all cause and respiratory-related acute outpatient care and emergency department visits. In this report, we describe the design and methods for the REDEFINE trial. Trial registration: NCT03137303https://clinicaltrials.gov/ct2/show/NCT03137303?term=REDEFINE&draw=2&rank=1.
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Patel B, Priefer R. Impact of chronic obstructive pulmonary disease, lung infection, and/or inhaled corticosteroids use on potential risk of lung cancer. Life Sci 2022; 294:120374. [DOI: 10.1016/j.lfs.2022.120374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/29/2022] [Accepted: 01/30/2022] [Indexed: 11/24/2022]
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Miravitlles M, Auladell-Rispau A, Monteagudo M, Vázquez-Niebla JC, Mohammed J, Nuñez A, Urrútia G. Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD. Eur Respir Rev 2021; 30:30/160/210075. [PMID: 34168063 DOI: 10.1183/16000617.0075-2021] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/26/2021] [Indexed: 11/05/2022] Open
Abstract
Inhaled corticosteroids (ICSs) are indicated for the prevention of exacerbations in COPD; however, a significant proportion of patients at low risk of exacerbations are treated with ICSs. We conducted a systematic review including a diversity of types of study designs and safety outcomes with the objective of describing the risk of adverse effects associated with the long-term use of ICSs in patients with COPD.A total of 90 references corresponding to 83 studies were included, including 26 randomised clinical trials (RCTs), 33 cohort studies, and 24 nested case-control (NCC) studies. Analysis of 19 RCTs showed that exposure to ICSs for ≥1 year increased the risk of pneumonia by 41% (risk ratio 1.41, 95% CI 1.23-1.61). Additionally, cohort and NCC studies showed an association between ICSs and risk of tuberculosis and mycobacterial disease. There was a strong association between ICS use and local disorders such as oral candidiasis and dysphonia. The association between ICSs and the risk of diabetes and fractures was less clear and appeared significant only at high doses of ICSs.Since most patients with COPD are elderly and with frequent comorbidities, an adequate risk-benefit balance is crucial for the indication of ICSs.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Both authors contributed equally and are considered first authors
| | - Ariadna Auladell-Rispau
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Both authors contributed equally and are considered first authors
| | - Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Medicine Dept, Universitat Autònoma de Barcelona (UAB), Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Juan Carlos Vázquez-Niebla
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | - Alexa Nuñez
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gerard Urrútia
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Lee JH, Park YH, Kang DR, Lee SJ, Lee MK, Kim SH, Yong SJ, Lee WY. Risk of Pneumonia Associated with Inhaled Corticosteroid in Patients with Chronic Obstructive Pulmonary Disease: A Korean Population-Based Study. Int J Chron Obstruct Pulmon Dis 2020; 15:3397-3406. [PMID: 33402820 PMCID: PMC7778438 DOI: 10.2147/copd.s286149] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Inhaled corticosteroids (ICSs) are recommended for patients with frequent exacerbation of chronic obstructive pulmonary disease (COPD). However, accumulating evidence has indicated the risk of pneumonia from the use of ICS. This study aimed to investigate the association between ICS and pneumonia in the real-world clinical setting. Methods A retrospective cohort study was performed using nationwide population data from the Korea National Health Insurance Service. Subjects who had a new diagnosis of COPD and who received inhaled bronchodilators without a diagnosis of pneumonia before the initiation of bronchodilators were identified. Subjects were followed up until their first diagnosis of pneumonia. The risk of pneumonia in ICS users was compared to that in non-ICS users. Results A total of 87,594 subjects were identified and 1:1 matched to 22,161 ICS users and non-ICS users. More ICS users were diagnosed with pneumonia compared to non-ICS users (33.73% versus 24.51%, P<0.0001). The incidence rate per 100,000 person-years was 8904.98 for ICS users and 6206.79 for non-ICS users. The hazard ratio (HR) of pneumonia for ICS users was 1.62 (95% CI 1.54–1.70). The HR of subjects prescribed with the lowest ICS cumulative dose was 1.35 (1.27–1.43). The HR increased to 1.51 (1.42–1.60), 1.96 (1.85–2.09), and 2.03 (1.89–2.18) as the cumulative dose increased. Pneumonia was strongly associated with fluticasone propionate (1.79 (1.70–1.89)) and fluticasone furoate (1.80 (1.61–2.01)) use, compared to the use of other types of ICS. Conclusion ICS increases the risk of pneumonia in patients with COPD. Hence, ICS should be carefully prescribed in patients with risk factors for pneumonia while considering the cumulative doses and subtypes of ICS.
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Affiliation(s)
- Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - You Hyun Park
- Department of Biostatistics, Yonsei University, Seoul, Korea
| | - Dae Ryong Kang
- Department of Precision Medicine & Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Myoung Kyu Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang-Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Suk Joong Yong
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Saito Z, Yoshida M, Kojima A, Tamura K, Hasegawa T, Kuwano K. Benefits and Risks of Inhaled Corticosteroid Treatment in Patients with Chronic Obstructive Pulmonary Disease Classified by Blood Eosinophil Counts. Lung 2020; 198:925-931. [PMID: 33068153 DOI: 10.1007/s00408-020-00397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) typically includes neutrophilic airway inflammation and eosinophilic inflammation in some cases. Inhaled corticosteroid (ICS) suppresses eosinophilic inflammation of the airway and reduces acute exacerbation (AE). The present study investigated the relationship between ICS and AE in patients with COPD classified by blood eosinophil counts. METHODS Overall, 244 patients with COPD were retrospectively evaluated between 2014 and 2017 and classified into two groups based on blood eosinophil counts (≥ 300/μL and < 300/μL). These patients were then reclassified into subgroups of those with and without ICS. Differences in the characteristics and incidence of AE and pneumonia with AE in each subgroup were evaluated retrospectively. RESULTS All patients with ICS used 320 μg budesonide twice daily. In the group with blood eosinophil counts ≥ 300/μL, patients with ICS had a significantly lower incidence of AE than those without ICS (P = 0.023). Meanwhile, no significant differences were observed in incidence of AE in the group with blood eosinophil counts < 300/μL. In the group with blood eosinophil counts < 300/μL, patients with ICS had a higher incidence of pneumonia with AE (P = 0.009). Conversely, no significant differences were observed in the group with blood eosinophil counts ≥ 300/μL. CONCLUSIONS ICS significantly reduced AE in COPD patients with blood eosinophil counts ≥ 300/μL. Meanwhile, ICS significantly increased pneumonia rate in patients with blood eosinophil count < 300/μL. Blood eosinophil count may be a useful indicator to identify the benefits and risks of ICS in COPD.
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Affiliation(s)
- Zenya Saito
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan.
| | - Masahiro Yoshida
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Ayako Kojima
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Kentaro Tamura
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Tsukasa Hasegawa
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Kazuyoshi Kuwano
- Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Avdeev SN, Trushenko NV, Merzhoeva ZM, Ivanova MS, Kusraeva EV. [Eosinophilic inflammation in chronic obstructive pulmonary disease]. TERAPEVT ARKH 2019; 91:144-152. [PMID: 32598645 DOI: 10.26442/00403660.2019.10.000426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease that combines various clinical manifestations and pathophysiological mechanisms. It underlies the separation of patients with COPD by phenotypes, endotypes and a personalized therapy of this disease. The implementation of this approach is possible only with the use of appropriate biomarkers. One of the most important biomarkers of COPD is eosinophilia of blood and/or sputum, which is considered as a predictor of frequent exacerbations and the effectiveness of inhaled glucocorticosteroids in patients with COPD. The literature discusses the impact of eosinophilic inflammation on the prognosis, clinical and functional parameters in COPD, and the role of the targeted therapy in the treatment of eosinophilic COPD.
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Affiliation(s)
- S N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Scientific Research Institute
| | - N V Trushenko
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Scientific Research Institute
| | - Z M Merzhoeva
- Sechenov First Moscow State Medical University (Sechenov University).,Pulmonology Scientific Research Institute
| | - M S Ivanova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E V Kusraeva
- Sechenov First Moscow State Medical University (Sechenov University)
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Wang CY, Lin YS, Wang YH, Lai CC, Wang HC, Chen L, Yu CJ. Risk of sepsis among patients with COPD treated with fixed combinations of inhaled corticosteroids and long-acting Beta2 agonists. Aging (Albany NY) 2019; 11:6863-6871. [PMID: 31509517 PMCID: PMC6756880 DOI: 10.18632/aging.102217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/14/2019] [Indexed: 11/25/2022]
Abstract
This study aimed to compare the effect of budesonide/formoterol and fluticasone/salmeterol on the risk and outcomes of sepsis in COPD patients. We conducted this study using the Taiwan National Health Insurance Research Database. We included COPD patients prescribed with budesonide/formoterol or fluticasone/salmeterol between 2004 and 2011. Outcomes including sepsis and mortality were measured. 10,267 COPD patients who received fluticasone/salmeterol and 6,844 patients who received budesonide/formoterol were enrolled into this study and then subsequence were adjusted by propensity score weighting. The incidence of sepsis was 5.74 and 4.99 per 100 person-years for the patients receiving fluticasone/salmeterol and budesonide/formoterol, respectively. Fluticasone/salmeterol was associated with higher risk of sepsis (aHR, 1.15; 95%CI, 1.07-1.24) and septic shock (aHR, 1.14; 95%CI, 1.01-1.29) than budesonide/formoterol. Besides, fluticasone/salmeterol was associated with higher risk of death (aHR, 1.090; 95%CI, 1.01-1.18) than budesonide/formoterol. Patients receiving fluticasone/salmeterol had a significant higher risk of sepsis related respiratory organ dysfunction, lower respiratory tract infection, genitourinary tract infection, bacteremia and skin infection. In conclusion, long-term treatment with budesonide/formoterol was associated with lower rates of sepsis and deaths than fluticasone/salmeterol in patients with COPD.
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Affiliation(s)
- Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - You Shuei Lin
- Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
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Almagro P, Martinez-Camblor P, Soriano JB. Inhaled corticosteroids and pneumonia mortality in COPD patients. Eur Respir J 2019; 54:1901035. [PMID: 31488585 DOI: 10.1183/13993003.01035-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Pere Almagro
- Multimorbidity Patients Unit, Internal Medicine Dept, University Hospital Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | | | - Joan B Soriano
- Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, CIBERES, Instituto de Salud Carlos III, Madrid, España
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11
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Suissa S. Inhaled corticosteroids preventing pneumonia mortality: paradox or selection bias? Eur Respir J 2019; 53:53/2/1802112. [PMID: 30765484 DOI: 10.1183/13993003.02112-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/30/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Samy Suissa
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, and the Depts of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, QC, Canada
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Liapikou A, Cilloniz C, Torres A. Drugs that increase the risk of community-acquired pneumonia: a narrative review. Expert Opin Drug Saf 2018; 17:991-1003. [PMID: 30196729 DOI: 10.1080/14740338.2018.1519545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP), a major cause of morbidity and mortality, is the leading infectious cause of death in the developed world. Population-based studies and systematic reviews have identified a large number of risk factors for the development of pneumonia in adults. In addition to age, lifestyle habits, and comorbidities, some forms of pharmacotherapy may also increase the risk for CAP. AREAS COVERED MEDLINE, CENTRAL, and Web of Science were used in 2017 to search for case-control, cohort studies, as well as randomized controlled trials and meta-analysis that involved outpatient proton pump inhibitors (PPIs), inhaled corticosteroids (ICSs), antipsychotics, oral antidiabetics, and CAP diagnosis in patients aged >18 years. EXPERT OPINION Our review confirmed that the use of ICSs, PPIs or antipsychotic drugs was independently associated with an increased risk for CAP. We also identified a positive association between specific oral antidiabetics and the development of pneumonia.
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Affiliation(s)
- Adamantia Liapikou
- a 6th Respiratory Department , Sotiria Chest Diseases Hospital , Athens , Greece
| | - Catia Cilloniz
- b Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) , Barcelona , Spain
| | - Antoni Torres
- b Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) , Barcelona , Spain
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Janson C, Johansson G, Ställberg B, Lisspers K, Olsson P, Keininger DL, Uhde M, Gutzwiller FS, Jörgensen L, Larsson K. Identifying the associated risks of pneumonia in COPD patients: ARCTIC an observational study. Respir Res 2018; 19:172. [PMID: 30200965 PMCID: PMC6131919 DOI: 10.1186/s12931-018-0868-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. This study assessed the risk of pneumonia associated with ICS in patients with COPD. Methods Electronic Medical Record data linked to National Health Registries were collected from COPD patients and matched reference controls in 52 Swedish primary care centers (2000–2014). Levels of ICS treatment (high, low, no ICS) and associated comorbidities were assessed. Patients were categorized by airflow limitation severity. Results A total of 6623 patients with COPD and 48,566 controls were analyzed. Patients with COPD had a more than 4-fold increase in pneumonia versus reference controls (hazard ratio [HR] 4.76, 95% confidence interval [CI]: 4.48–5.06). ICS use increased the risk of pneumonia by 20–30% in patients with COPD with forced expiratory volume in 1 s ≥ 50% versus patients not using ICS. Asthma was an independent risk factor for pneumonia in the COPD population. Multivariate analysis identified independent predictors of pneumonia in the overall population. The highest risk of pneumonia was associated with high dose ICS (HR 1.41, 95% CI: 1.23–1.62). Conclusions Patients with COPD have a greater risk of pneumonia versus reference controls; ICS use and concurrent asthma increased the risk of pneumonia further.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset, 75185, Uppsala, Sweden.
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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14
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Restrepo MI, Sibila O, Anzueto A. Pneumonia in Patients with Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2018; 81:187-197. [PMID: 29962118 PMCID: PMC6030662 DOI: 10.4046/trd.2018.0030] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 11/24/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a frequent comorbid condition associated with increased morbidity and mortality. Pneumonia is the most common infectious disease condition. The purpose of this review is to evaluate the impact of pneumonia in patients with COPD. We will evaluate the epidemiology and factors associated with pneumonia. We are discussing the clinical characteristics of COPD that may favor the development of infections conditions such as pneumonia. Over the last 10 years, there is an increased evidence that COPD patients treated with inhaled corticosteroids are at increased risk to develp pneumonia. We will review the avaialbe information as well as the possible mechanism for this events. We also discuss the impact of influenza and pneumococcal vaccination in the prevention of pneumonia in COPD patients.
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Affiliation(s)
- Marcos I Restrepo
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT) (MR), San Antonio, TX, USA
| | - Oriol Sibila
- Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, TX, USA
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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15
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Chung WS, Lin CL. Acute respiratory events in patients with bronchiectasis-COPD overlap syndrome: A population-based cohort study. Respir Med 2018; 140:6-10. [PMID: 29957282 DOI: 10.1016/j.rmed.2018.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 09/26/2017] [Accepted: 05/11/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND The clinical phenotypes of chronic obstructive pulmonary disease (COPD) are related to various outcomes. We investigated the risk of acute respiratory events in patients with bronchiectasis-COPD overlap syndrome (BCOS) in Taiwan. METHODS We included 3955 patients who received diagnoses of COPD and bronchiectasis from 2000 to 2007 from the Taiwan Longitudinal Health Insurance Database in the BCOS cohort. In the comparison cohort, we included patients with COPD but without bronchiectasis at a ratio of 4:1, frequency matched by age, sex, and index year with each patient with BCOS. We followed both cohorts for 5 years to investigate the incidence and risk of acute respiratory events in the BCOS cohort relative to the comparison cohort, the incidence rate ratios (IRRs) and corresponding 95% confidence intervals (CIs) were determined using Poisson regression models. RESULTS The BCOS cohort experienced more episodes of acute respiratory events than did the comparison cohort (16.4 vs 5.52 per 100 person-y). After adjustment for potential covariates, the BCOS cohort had a 2.20-fold higher risk of pneumonia (adjusted IRR = 2.20, 95% CI = 2.06-2.34), a 3.88-fold higher risk of acute exacerbation (adjusted IRR = 3.88,95% CI = 3.64-4.13), a 1.74-fold higher risk of acute respiratory failure (adjusted IRR = 1.74,95% CI = 1.47-2.06), and a 1.99-fold higher risk of cardiopulmonary arrest (adjusted IRR = 1.99,95% CI = 1.81-2.20) than did the comparison cohort. CONCLUSION The patients with BCOS had a higher risk of acute respiratory events than did COPD patients without bronchiectasis.
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Affiliation(s)
- Wei-Sheng Chung
- Department of Internal Medicine, Taichung Hospital, Ministry of Health and Welfare, Taichung, Taiwan; Department of Health Services Administration, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan.
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
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16
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Cascini S, Kirchmayer U, Belleudi V, Bauleo L, Pistelli R, Di Martino M, Formoso G, Davoli M, Agabiti N. Inhaled Corticosteroid Use in Chronic Obstructive Pulmonary Disease and Risk of Pneumonia: A Nested Case-Control Population-based Study in Lazio (Italy)-The OUTPUL Study. COPD 2017; 14:311-317. [PMID: 28406337 DOI: 10.1080/15412555.2016.1254172] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Inhaled corticosteroid (ICS) use in chronic obstructive pulmonary disease (COPD) patients is associated with a reduction of exacerbations and a potential risk of pneumonia. The objective was to determine if ICS use, with or without long-acting β2-agonist, increases pneumonia risk in COPD patients. A cohort study was performed using linked hospital and drug prescription databases in the Lazio region. Patients (45+) discharged with COPD in 2006-2009 were enrolled and followed from cohort entry until first admission for pneumonia, death or study end, 31 December, 2012. A nested case-control approach was used to estimate the rate ratio (RR) associated with current or past use of ICS adjusted for age, gender, number of exacerbations in the previous year and co-morbidities. Current users were defined as patients with their last ICS prescribed in the 60 days prior to the event. Past users were those with the last prescription between 61 and 365 days before the event. Current use was classified into three levels (high, medium, low) according to the medication possession ratio. Among the cohort of 19288 patients, 3141 had an event of pneumonia (incidence rate for current use 87/1000py, past use 32/1000py). After adjustment, patients with current use were 2.29 (95% confidence interval [CI]: 1.99-2.63) times more likely to be hospitalised for pneumonia with respect to no use; for past use RR was 1.23 (95% CI: 1.07-1.42). For older patients (80+), the rate was higher than that for younger patients. ICS use was associated with an excess risk of pneumonia. The effect was greatest for higher doses and in the very elderly.
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Affiliation(s)
- Silvia Cascini
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
| | - Ursula Kirchmayer
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
| | - Valeria Belleudi
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
| | - Lisa Bauleo
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
| | - Riccardo Pistelli
- b Department of Respiratory Physiology , Catholic University , Rome , Italy
| | - Mirko Di Martino
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
| | - Giulio Formoso
- c Emilia-Romagna Regional Health and Social Care Agency , Bologna , Italy
| | - Marina Davoli
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
| | - Nera Agabiti
- a Department of Epidemiology , Lazio Regional Health Service , Rome , Italy
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17
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Wu MF, Jian ZH, Huang JY, Jan CF, Nfor ON, Jhang KM, Ku WY, Ho CC, Lung CC, Pan HH, Wu MC, Liaw YP. Post-inhaled corticosteroid pulmonary tuberculosis and pneumonia increases lung cancer in patients with COPD. BMC Cancer 2016; 16:778. [PMID: 27724847 PMCID: PMC5057453 DOI: 10.1186/s12885-016-2838-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 10/05/2016] [Indexed: 12/26/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) have been associated with decreased lung cancer risk. However, they have been associated with pulmonary infections (tuberculosis [TB] and pneumonia) in patients with chronic obstructive pulmonary disease (COPD). TB and pneumonia have increased lung cancer risk. The association between post-ICS pulmonary infections and lung cancer remains unclear. Methods We conducted a retrospective cohort study from 2003 to 2010 using the Taiwan National Health Insurance Research Database. Among the 1,089,955 patients with COPD, we identified 8813 new users of ICS prescribed for a period of 3 months or more and 35,252 non-ICS users who were randomly matched for sex, age and date of ICS use from 2003 to 2005. Cox proportional hazard regression was used to estimate the hazard ratio (HR) of pulmonary infections in patients with/without ICS use. Results The HRs for lung cancer in ICS users with sequential lung infections were as follows; 2.42 (95 % confidence interval [CI], 1.28–4.58) for individuals with TB, 2.37 (95 % CI, 1.01–5.54) for TB and pneumonia, and 1.17(95 % CI, 0.69–1.98) for those with pneumonia. For non-ICS users with pulmonary infections, the HRs were 1.68 (95 % CI, 0.78–3.65) for individual with TB and pneumonia, 1.42 (95 % CI, 0.89–2.26) for TB, and 0.95 (95 % CI, 0.62–1.46) for individuals with pneumonia. Conclusions COPD patients with TB /or pneumonia who used ICS had increased risk of lung cancer. Because the overall prognosis of lung cancer remains poor, screening tests are recommended for patients with these conditions.
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Affiliation(s)
- Ming-Fang Wu
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan.,Divisions of Medical Oncology and Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - Zhi-Hong Jian
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Jing-Yang Huang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Cheng-Feng Jan
- Office of Physical Education, Chung Yuan Christian University, Taoyuan City, Taiwan
| | - Oswald Ndi Nfor
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Kai-Ming Jhang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan.,Department of Neurology, Lu-Tung Christian Hospital, Changhua, Taiwan
| | - Wen-Yuan Ku
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Chien-Chang Ho
- Department of Physical Education, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chia-Chi Lung
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan.,Department of Family and Community Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Hui-Hsien Pan
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan.,Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - Min-Chen Wu
- Office of Physical Education, Chung Yuan Christian University, Taoyuan City, Taiwan
| | - Yung-Po Liaw
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan. .,Department of Family and Community Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan.
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18
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Sharafkhaneh A, Spiegelman AM, Main K, Tavakoli-Tabasi S, Lan C, Musher D. Mortality in Patients Admitted for Concurrent COPD Exacerbation and Pneumonia. COPD 2016; 14:23-29. [PMID: 27661473 DOI: 10.1080/15412555.2016.1220513] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Further, it is unknown how this interaction changes over time. We explored the effect of pneumonia and COPD on inpatient, 30-day and overall mortality. We used a Veterans Health Affairs database to compare patients who were hospitalized for a COPD exacerbation without pneumonia (AECOPD), patients hospitalized for pneumonia without COPD (PNA) and patients hospitalized for pneumonia who had a concurrent diagnosis of COPD (PCOPD). We studied records of 15,065 patients with the following primary discharge diagnoses: (a) AECOPD cohort (7,154 individuals); (b) PNA cohort (4,433 individuals); and (c) PCOPD (3,478 individuals), comparing inpatient, 30-day and overall mortality in the three study cohorts. We observed a stepwise increase in inpatient mortality for AECOPD, PNA and PCOPD (4.8%, 9.5% and 13.2%, respectively). These differences persisted at 30 days post-discharge (AECOPD = 6.7%, PNA = 12.4% and PCOPD = 14.6%; p < 0.0001), but not throughout the study period (median follow-up: 37 months). With time, the death rate rose disproportionally in patients who had been admitted for AECOPD (AECOPD = 64.5%; PNA = 57.4% and PCOPD 66.2%; p < 0.001). In multivariate analysis, PCOPD predicted the greatest inpatient mortality (p < 0.001). The data showed a progression in inpatient and 30-day mortality from AECOPD to PNA to PCOPD. Pneumonia and COPD differentially affected inpatient, 30-day and overall mortality with pneumonia affecting predominantly inpatient and 30-day mortality while COPD affecting the overall mortality.
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Affiliation(s)
- Amir Sharafkhaneh
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,b Department of Medicine , Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston , TX , USA
| | | | - Kevin Main
- d Allied Health Sciences, Baylor College of Medicine , Houston , TX , USA
| | - Shahriar Tavakoli-Tabasi
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,c Department of Medicine , Section of Infectious Diseases, Baylor College of Medicine , Houston , TX , USA
| | - Charlie Lan
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,b Department of Medicine , Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston , TX , USA
| | - Daniel Musher
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,c Department of Medicine , Section of Infectious Diseases, Baylor College of Medicine , Houston , TX , USA
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19
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Jian ZH, Huang JY, Lin FCF, Nfor ON, Jhang KM, Ku WY, Ho CC, Lung CC, Pan HH, Wu MC, Wu MF, Liaw YP. Post-Inhaled Corticosteroid Pulmonary Tuberculosis Increases Lung Cancer in Patients with Asthma. PLoS One 2016; 11:e0159683. [PMID: 27448321 PMCID: PMC4957793 DOI: 10.1371/journal.pone.0159683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/05/2016] [Indexed: 12/19/2022] Open
Abstract
Purpose To evaluate the association between post-inhaled corticosteroid (ICS) pulmonary tuberculosis (TB), pneumonia and lung cancer in patients with asthma. Methods The study samples were collected from the National Health Insurance Database. Asthmatic patients who were first-time users of ICS between 2003 and 2005 were identified as cases. For each case, 4 control individuals were randomly matched for sex, age and date of ICS use. Cases and matched controls were followed up until the end of 2010. Cox proportional hazard regression was used to determine the hazard ratio for pulmonary infections and lung cancer risk in the ICS users and non-users. Results A total of 10,904 first-time users of ICS were matched with 43,616 controls. The hazard ratios for lung cancer were: 2.52 (95% confidence interval [CI], 1.22–5.22; p = 0.012) for individuals with post-ICS TB, 1.28 (95%CI, 0.73–2.26; p = 0.389) for post-ICS pneumonia, 2.31(95%CI, 0.84–6.38; p = 0.105) for post-ICS pneumonia+TB, 1.08 (95%CI, 0.57–2.03; p = 0.815) for TB, 0.99 (95%CI, 0.63–1.55; p = 0.970) for pneumonia, and 0.32 (95%CI, 0.05–2.32; p = 0.261) for pneumonia+ TB, respectively. Conclusions Post-ICS TB increased lung cancer risk in patients with asthma. Because of the high mortality associated with lung cancer, screening tests are recommended for patients with post-ICS TB.
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Affiliation(s)
- Zhi-Hong Jian
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Jing-Yang Huang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Frank Cheau-Feng Lin
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
- Department of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - Oswald Ndi Nfor
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Kai-Ming Jhang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Yuan Ku
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Chien-Chang Ho
- Department of Physical Education, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chia-Chi Lung
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
- Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - Hui-Hsien Pan
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - Min-Chen Wu
- Office of Physical Education, Chung Yuan Christian University, Taoyuan City, Taiwan
| | - Ming-Fang Wu
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
- Divisions of Medical Oncology and Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan
- * E-mail: (YPL); (MFW)
| | - Yung-Po Liaw
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
- Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan
- * E-mail: (YPL); (MFW)
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20
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Yamauchi Y, Yasunaga H, Hasegawa W, Sakamoto Y, Takeshima H, Jo T, Matsui H, Fushimi K, Nagase T. Effect of outpatient therapy with inhaled corticosteroids on decreasing in-hospital mortality from pneumonia in patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:1403-11. [PMID: 27382276 PMCID: PMC4922764 DOI: 10.2147/copd.s107985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and objectives Inhaled corticosteroids (ICS) and long-acting inhaled bronchodilators (IBD) are beneficial for the management of COPD. Although ICS has been reported to increase the risk of pneumonia in patients with COPD, it remains controversial whether it influences mortality. Using a Japanese national database, we examined the association between preadmission ICS therapy and in-hospital mortality from pneumonia in patients with COPD. Methods We retrospectively collected data from 1,165 hospitals in Japan on patients with COPD who received outpatient inhalation therapy and were admitted with pneumonia. Patients were categorized into those who received ICS with IBD and those who received IBD alone. We performed multivariate logistic regression analysis to examine the association between outpatient ICS therapy and in-hospital mortality, adjusting for the patients’ backgrounds. Results Of the 7,033 eligible patients, the IBD alone group (n=3,331) was more likely to be older, have lower body mass index, poorer general conditions, and more severe pneumonia than the ICS with IBD group (n=3,702). In-hospital mortality was 13.2% and 8.1% in the IBD alone and the ICS with IBD groups, respectively. After adjustment for patients’ backgrounds, the ICS with IBD group had significantly lower mortality than the IBD alone group (adjusted odds ratio, 0.80; 95% confidence interval, 0.68–0.94). Higher mortality was associated with older age, being male, lower body mass index, poorer general status, and more severe pneumonia. Conclusion Outpatient inhaled ICS and IBD therapy was significantly associated with lower mortality from pneumonia in patients with COPD than treatment with IBD alone.
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Affiliation(s)
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Wakae Hasegawa
- Department of Respiratory Medicine, Graduate School of Medicine
| | - Yukiyo Sakamoto
- Department of Respiratory Medicine, Graduate School of Medicine
| | | | - Taisuke Jo
- Department of Respiratory Medicine, Graduate School of Medicine; Division for Health Service Promotion, The University of Tokyo
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate School of Medicine
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21
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Abstract
Chronic obstructive pulmonary disease (COPD) is one of the main causes of human mortalities globally after heart disease and stroke. There is increasing evidence of an aetiological association between COPD and pneumonia, the leading infectious cause of death globally in children under 5 years. In this review, we discuss the known risk factors of COPD that are also shared with pneumonia including smoking, air pollution, age and immune suppression. We review how lung pathology linked to a previous history of pneumonia may heighten susceptibility to the development of COPD in later life. Furthermore, we examine how specific aspects of COPD immunology could contribute to the manifestation of pneumonia. Based on the available evidence, a convergent relationship is becoming apparent with respect to the pathogenesis of COPD and pneumonia. This has implications for the management of both diseases, and the development of new interventions.
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Affiliation(s)
- Sanjay S Gautam
- a Breathe Well Centre, School of Medicine, University of Tasmania , Hobart , Australia
| | - Ronan F O'Toole
- a Breathe Well Centre, School of Medicine, University of Tasmania , Hobart , Australia
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22
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Iannella H, Luna C, Waterer G. Inhaled corticosteroids and the increased risk of pneumonia: what's new? A 2015 updated review. Ther Adv Respir Dis 2016; 10:235-55. [PMID: 26893311 PMCID: PMC5933605 DOI: 10.1177/1753465816630208] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
There is a considerable amount of evidence that supports the possibility of an increased risk of pneumonia associated with prolonged use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD). However, as yet, no statistically significant increase in pneumonia-related 30-day mortality in patients on ICS has been demonstrated. The lack of objective pneumonia definitions and radiological confirmations have been a major source of bias, because of the similarities in clinical presentation between pneumonia and acute exacerbations of COPD. One of the newer fluticasone furoate studies overcomes these limitations and also provides an assessment of a range of doses, suggesting that the therapeutic window is quite narrow and that conventional dosing has probably been too high, although the absolute risk may be different compared to other drugs. Newer studies were not able to rule out budesonide as responsible for pneumonia, as previous evidence suggested, and there is still need for evidence from head-to-head comparisons in order to better assess possible intra-class differences. Although the exact mechanisms by which ICS increase the risk of pneumonia are not fully understood, the immunosuppressive effects of ICS on the respiratory epithelium and the disruption of the lung microbiome are most likely to be implicated. Given that COPD represents such a complex and heterogeneous disease, attempts are being made to identify clinical phenotypes with clear therapeutic implications, in order to optimize the pharmacological treatment of COPD and avoid the indiscriminate use of ICS. If deemed necessary, gradual withdrawal of ICS appears to be well tolerated. Vaccination against pneumococcus and influenza should be emphasized in patients with COPD receiving ICS. Physicians should keep in mind that signs and symptoms of pneumonia in COPD patients may be initially indistinguishable from those of an exacerbation, and that patients with COPD appear to be at increased risk of developing pneumonia as a complication of ICS therapy.
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Affiliation(s)
- Hernan Iannella
- Hospital de Clínicas 'José de San Martin', Universidad de Buenos Aires, Av. Córdoba 2351, Ciudad de Buenos Aries, C1120AAR, Argentina
| | - Carlos Luna
- Hospital de Clínicas 'José de San Martin', Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Grant Waterer
- Royal Perth Hospital, University of Western Australia, Western Australia, Australia
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23
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Festic E, Bansal V, Gupta E, Scanlon PD. Association of Inhaled Corticosteroids with Incident Pneumonia and Mortality in COPD Patients; Systematic Review and Meta-Analysis. COPD 2016; 13:312-26. [PMID: 26645797 PMCID: PMC4951104 DOI: 10.3109/15412555.2015.1081162] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Inhaled corticosteroids are commonly prescribed for patients with severe COPD. They have been associated with increased risk of pneumonia but not with increased pneumonia-associated or overall mortality. METHODS To further examine the effects of inhaled corticosteroids on pneumonia incidence, and mortality in COPD patients, we searched for potentially relevant articles in PubMed, Medline, CENTRAL, EMBASE, Scopus, Web of Science and manufacturers' web clinical trial registries from 1994 to February 4, 2014. Additionally, we checked the included and excluded studies' bibliographies. We subsequently performed systematic review and meta-analysis of included randomized controlled trials and observational studies on the topic. RESULTS We identified 38 studies: 29 randomized controlled trials and nine observational studies. The estimated unadjusted risk of pneumonia was increased in randomized trials: RR 1.61; 95% CI 1.35-1.93, p < 0.001; as well as in observational studies: OR 1.89; 95% CI 1.39-2.58, p < 0·001. Six randomized trials and seven observational studies were useful in estimating unadjusted risk of pneumonia -case-fatality: RR 0.91; 95% CI 0.52-1.59, p = 0.74; and OR 0.72; 95% CI 0.59-0.88, p = 0.001, respectively. Twenty-nine randomized trials and six observational studies allowed estimation of unadjusted risk of overall mortality: RR 0.95; 95% CI 0.85-1.05, p = 0.31; and OR 0.79; 95% CI 0.65-0.97, p = 0.02, respectively. CONCLUSIONS Despite a substantial and significant increase in unadjusted risk of pneumonia associated with inhaled corticosteroid use, pneumonia fatality and overall mortality were found not to be increased in randomized controlled trials and were decreased in observational studies.
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Affiliation(s)
- Emir Festic
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Vikas Bansal
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Ena Gupta
- Internal Medicine, University of Florida/SHANDS, Jacksonville, Florida
| | - Paul D. Scanlon
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Kim KH, Park TS, Kim YS, Lee JS, Oh YM, Lee SD, Lee SW. Resolvin D1 prevents smoking-induced emphysema and promotes lung tissue regeneration. Int J Chron Obstruct Pulmon Dis 2016; 11:1119-28. [PMID: 27313451 PMCID: PMC4890694 DOI: 10.2147/copd.s100198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Emphysema is an irreversible disease that is characterized by destruction of lung tissue as a result of inflammation caused by smoking. Resolvin D1 (RvD1), derived from docosahexaenoic acid, is a novel lipid that resolves inflammation. The present study tested whether RvD1 prevents smoking-induced emphysema and promotes lung tissue regeneration. Materials and methods C57BL/6 mice, 8 weeks of age, were randomly divided into four groups: control, RvD1 only, smoking only, and smoking with RvD1 administration. Four different protocols were used to induce emphysema and administer RvD1: mice were exposed to smoking for 4 weeks with poly(I:C) or to smoking only for 24 weeks, and RvD1 was injected within the smoking exposure period to prevent regeneration or after completion of smoking exposure to assess regeneration. The mean linear intercept and inflammation scores were measured in the lung tissue, and inflammatory cells and cytokines were measured in the bronchoalveolar lavage fluid. Results Measurements of mean linear intercept showed that RvD1 significantly attenuated smoking-induced lung destruction in all emphysema models. RvD1 also reduced smoking-induced inflammatory cell infiltration, which causes the structural derangements observed in emphysema. In the 4-week prevention model, RvD1 reduced the smoking-induced increase in eosinophils and interleukin-6 in the bronchoalveolar lavage fluid. In the 24-week prevention model, RvD1 also reduced the increased neutrophils and total cell counts induced by smoking. Conclusion RvD1 attenuated smoking-induced emphysema in vivo by reducing inflammation and promoting tissue regeneration. This result suggests that RvD1 may be useful in the prevention and treatment of emphysema.
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Affiliation(s)
- Kang-Hyun Kim
- Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tai Sun Park
- Department of Pulmonology and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - You-Sun Kim
- Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonology and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Mok Oh
- Department of Pulmonology and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Do Lee
- Department of Pulmonology and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonology and Critical Care Medicine, Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Yang IA, Shaw JG, Goddard JR, Clarke MS, Reid DW. Use of inhaled corticosteroids in COPD: improving efficacy. Expert Rev Respir Med 2016; 10:339-50. [DOI: 10.1586/17476348.2016.1151789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Lee MC, Lee CH, Chien SC, Chang JH, She HL, Wang JY, Yu MC. Inhaled Corticosteroids Increase the Risk of Pneumonia in Patients With Chronic Obstructive Pulmonary Disease: A Nationwide Cohort Study. Medicine (Baltimore) 2015; 94:e1723. [PMID: 26496284 PMCID: PMC4620770 DOI: 10.1097/md.0000000000001723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The association of inhaled corticosteroids (ICS) and pneumonia in patients with chronic obstructive pulmonary disease (COPD) is still controversial.From the National Health Insurance Database of Taiwan, COPD cases with history of acute exacerbation (AE) were identified (COPD cohort). Time-dependent Cox regression analysis was applied to investigate the risk factors for pneumonia with COPD severity controlled by surrogate variables. Among the COPD cohort, those who continuously used ICS for more than 360 days without interruption were selected (ICS cohort). The incidence rate of pneumonia during ICS use was compared with those before ICS use and after ICS discontinuation by using pair t test.A total of 6034 and 842 cases were identified as the COPD and ICS cohorts, respectively. In the COPD cohort, recent ICS use was independently associated with pneumonia (hazard ratio: 1.06 [1.02-1.11] for per 80 mg of budesonide). Other independent risk factors included age, male, diabetes mellitus, malignancy, low income, baseline pneumonia event, and recent use of oral corticosteroids and aminophylline. In the ICS cohort, while AE rate gradually decreased, the incidence rate of pneumonia significantly increased after ICS use (from 0.10 to 0.21 event/person-year, P = 0.001).This study demonstrates the association between ICS use and pneumonia in patients with COPD and history of AE. ICS should be judiciously used in indicated COPD patients.
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Affiliation(s)
- Ming-Chia Lee
- From the Department of Pharmacy, New Taipei City Hospital, New Taipei City, Taiwan (M-CL); Division of Pulmonary Medicine, Wanfang Hospital, Taipei Medical University, Taipei, Taiwan (C-HL, J-HC, H-LS, M-CY); School of Medicine, Taipei Medical University, Taipei, Taiwan (C-HL); Department of Pharmacy, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan (S-CC); Department of Internal Medicine, Taiwan University Hospital, Taipei, Taiwan (J-YW); and School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan (M-CY)
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Liapikou A, Toumbis M, Torres A. Managing the safety of inhaled corticosteroids in COPD and the risk of pneumonia. Expert Opin Drug Saf 2015; 14:1237-47. [DOI: 10.1517/14740338.2015.1057494] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Stolberg VR, McCubbrey AL, Freeman CM, Brown JP, Crudgington SW, Taitano SH, Saxton BL, Mancuso P, Curtis JL. Glucocorticoid-Augmented Efferocytosis Inhibits Pulmonary Pneumococcal Clearance in Mice by Reducing Alveolar Macrophage Bactericidal Function. THE JOURNAL OF IMMUNOLOGY 2015; 195:174-84. [PMID: 25987742 DOI: 10.4049/jimmunol.1402217] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 04/22/2015] [Indexed: 12/31/2022]
Abstract
Inhaled corticosteroids (ICS) increase community-acquired pneumonia (CAP) incidence in patients with chronic obstructive pulmonary disease (COPD) by unknown mechanisms. Apoptosis is increased in the lungs of COPD patients. Uptake of apoptotic cells (ACs) ("efferocytosis") by alveolar macrophages (AMøs) reduces their ability to combat microbes, including Streptococcus pneumoniae, the most common cause of CAP in COPD patients. Having shown that ICS significantly increase AMø efferocytosis, we hypothesized that this process, termed glucocorticoid-augmented efferocytosis, might explain the association of CAP with ICS therapy in COPD. To test this hypothesis, we studied the effects of fluticasone, AC, or both on AMøs of C57BL/6 mice in vitro and in an established model of pneumococcal pneumonia. Fluticasone plus AC significantly reduced TLR4-stimulated AMø IL-12 production, relative to either treatment alone, and decreased TNF-α, CCL3, CCL5, and keratinocyte-derived chemoattractant/CXCL1, relative to AC. Mice treated with fluticasone plus AC before infection with viable pneumococci developed significantly more lung CFUs at 48 h. However, none of the pretreatments altered inflammatory cell recruitment to the lungs at 48 h postinfection, and fluticasone plus AC less markedly reduced in vitro mediator production to heat-killed pneumococci. Fluticasone plus AC significantly reduced in vitro AMø killing of pneumococci, relative to other conditions, in part by delaying phagolysosome acidification without affecting production of reactive oxygen or nitrogen species. These results support glucocorticoid-augmented efferocytosis as a potential explanation for the epidemiological association of ICS therapy of COPD patients with increased risk for CAP, and establish murine experimental models to dissect underlying molecular mechanisms.
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Affiliation(s)
| | | | - Christine M Freeman
- Research Service, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109
| | - Jeanette P Brown
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109
| | - Sean W Crudgington
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109
| | - Sophina H Taitano
- Graduate Program in Immunology, University of Michigan, Ann Arbor, MI 48109
| | | | - Peter Mancuso
- Graduate Program in Immunology, University of Michigan, Ann Arbor, MI 48109; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109; and
| | - Jeffrey L Curtis
- Graduate Program in Immunology, University of Michigan, Ann Arbor, MI 48109; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109; Medical Service, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105
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Festic E, Scanlon PD. Incident pneumonia and mortality in patients with chronic obstructive pulmonary disease. A double effect of inhaled corticosteroids? Am J Respir Crit Care Med 2015; 191:141-8. [PMID: 25409118 DOI: 10.1164/rccm.201409-1654pp] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Inhaled corticosteroids are commonly prescribed for patients with severe chronic obstructive pulmonary disease. Although their use improves quality of life and reduces exacerbations, it is associated with increased risk of pneumonia. Curiously, their use has not been associated with increased risk of pneumonia-related or overall mortality. We review pertinent literature to further explore the effects of inhaled corticosteroids on incident pneumonia and mortality in patients with chronic obstructive pulmonary disease. The association of use of inhaled corticosteroids and incident pneumonia is substantial and has been present in the majority of the studies on the topic. This includes both randomized controlled trials and observational studies. However, all of the studies have substantial risk of bias. Most randomized trials are limited by lack of systematic ascertainment of pneumonia; they depended on adverse event reporting. Many observational studies included proper radiographic assessment of pneumonia, but they are limited by their retrospective, observational design. The unadjusted higher risk of pneumonia is associated with longer duration of use, more potent ICS compounds, and higher doses. That implies a dose-effect relationship. Unlike pneumonia, mortality is a precise outcome. Despite the robust association of inhaled corticosteroid use with increased risk of pneumonia, all studies find either no difference or a reduction in pulmonary-related and overall mortality associated with the use of inhaled corticosteroids. These observations suggest a double effect of inhaled corticosteroids (i.e., an adverse effect plus an unexplained mitigating effect).
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Affiliation(s)
- Emir Festic
- 1 Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida; and
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Collins BF, Feemster LC, Rinne ST, Au DH. Factors predictive of airflow obstruction among veterans with presumed empirical diagnosis and treatment of COPD. Chest 2015; 147:369-376. [PMID: 25079684 PMCID: PMC4314814 DOI: 10.1378/chest.14-0672] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/07/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite guideline recommendations, patients suspected of having COPD often are treated empirically instead of undergoing spirometry to confirm airflow obstruction (AFO). Accurate diagnosis and treatment are essential to provide high-quality, value-oriented care. We sought to identify predictors associated with AFO among patients with and treated for COPD prior to performance of confirmatory spirometry. METHODS We identified a cohort of veterans with spirometry performed at Pacific Northwest Department of Veterans Affairs medical centers between 2003 and 2007. We included only patients with empirically diagnosed COPD in the 2 years prior to spirometry who were also taking inhaled medication to treat COPD in the 1 year prior to spirometry. We used relative risk regression analysis to identify predictors of AFO. RESULTS Among patients empirically treated for COPD (N = 3,209), 62% had AFO. Risk factors such as older age, prior smoking status, and underweight status were associated with AFO on spirometry. In contrast, comorbidities often associated with somatic symptoms were associated with absence of AFO and included congestive heart failure, depression, diabetes, obesity, and sleep apnea. CONCLUSIONS Comorbidities associated with somatic complaints of dyspnea were associated with a lower risk of having airflow limitations, suggesting that empirical diagnosis and treatment of COPD may lead to inappropriate treatment of individuals who do not have AFO.
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Affiliation(s)
- Bridget F Collins
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Laura C Feemster
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Seppo T Rinne
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - David H Au
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
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Pneumonia Risk with Inhaled Fluticasone Furoate and Vilanterol Compared with Vilanterol Alone in Patients with COPD. Ann Am Thorac Soc 2015; 12:27-34. [DOI: 10.1513/annalsats.201409-413oc] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Davydow DS, Hough CL, Zivin K, Langa KM, Katon WJ. Depression and risk of hospitalization for pneumonia in a cohort study of older Americans. J Psychosom Res 2014; 77:528-34. [PMID: 25139125 PMCID: PMC4259844 DOI: 10.1016/j.jpsychores.2014.08.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 07/28/2014] [Accepted: 08/02/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study is to determine if depression is independently associated with risk of hospitalization for pneumonia after adjusting for demographics, medical comorbidity, health-risk behaviors, baseline cognition and functional impairments. METHODS This secondary analysis of prospectively collected data examined a population-based sample of 6704 Health and Retirement Study (HRS) (1998-2008) participants>50years old who consented to have their interviews linked to their Medicare claims and were without a dementia diagnosis. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. ICD-9-CM diagnoses were used to identify hospitalizations for which the principal discharge diagnosis was for bacterial or viral pneumonia. The odds of hospitalization for pneumonia for participants with depression relative to those without depression were estimated using logistic regression models. Population attributable fractions were calculated to determine the extent that hospitalizations for pneumonia could be attributable to depression. RESULTS After adjusting for demographic characteristics, clinical factors, and health-risk behaviors, depression was independently associated with increased odds of hospitalization for pneumonia (odds ratio [OR]: 1.28, 95% confidence interval [95%CI]: 1.08, 1.53). This association persisted after adjusting for baseline cognition and functional impairments (OR: 1.24, 95%CI: 1.03, 1.50). In this cohort, 6% (95%CI: 2%, 10%) of hospitalizations for pneumonia were potentially attributable to depression. CONCLUSION Depression is independently associated with increased odds of hospitalization for pneumonia. This study provides additional rationale for integrating mental health care into medical settings in order to improve outcomes for older adults.
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Affiliation(s)
- Dimitry S Davydow
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
| | - Catherine L Hough
- Department Internal Medicine, University of Washington, Seattle, WA, USA
| | - Kara Zivin
- Ann Arbor Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Kenneth M Langa
- Ann Arbor Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Wayne J Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Finney L, Berry M, Singanayagam A, Elkin SL, Johnston SL, Mallia P. Inhaled corticosteroids and pneumonia in chronic obstructive pulmonary disease. THE LANCET. RESPIRATORY MEDICINE 2014; 2:919-932. [PMID: 25240963 DOI: 10.1016/s2213-2600(14)70169-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Inhaled corticosteroids are widely used in chronic obstructive pulmonary disease (COPD) and, in combination with long-acting β2 agonists, reduce exacerbations and improve lung function and quality of life. However, inhaled corticosteroids have been linked with an increased risk of pneumonia in individuals with COPD, but the magnitude of this risk, the effects of different preparations and doses, and the mechanisms of this effect remain unclear. Therefore, making informed clinical decisions--balancing the beneficial and adverse effects of inhaled corticosteroids in individuals with COPD--is difficult. Understanding of the mechanisms of increased pneumonia risk with inhaled corticosteroids is urgently needed to clarify their role in the management of COPD and to aid the development of new, safer therapies.
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Affiliation(s)
- Lydia Finney
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Matthew Berry
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Aran Singanayagam
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Sarah L Elkin
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Patrick Mallia
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK.
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Dong YH, Chang CH, Wu FLL, Shen LJ, Calverley PM, Löfdahl CG, Lai MS, Mahler DA. Use of Inhaled Corticosteroids in Patients With COPD and the Risk of TB and Influenza. Chest 2014; 145:1286-1297. [DOI: 10.1378/chest.13-2137] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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DiSantostefano RL, Sampson T, Le HV, Hinds D, Davis KJ, Bakerly ND. Risk of pneumonia with inhaled corticosteroid versus long-acting bronchodilator regimens in chronic obstructive pulmonary disease: a new-user cohort study. PLoS One 2014; 9:e97149. [PMID: 24878543 PMCID: PMC4039434 DOI: 10.1371/journal.pone.0097149] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 04/15/2014] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Observational studies using case-control designs have showed an increased risk of pneumonia associated with inhaled corticosteroid (ICS)-containing medications in patients with chronic obstructive pulmonary disease (COPD). New-user observational cohort designs may minimize biases associated with previous case-control designs. OBJECTIVE To estimate the association between ICS and pneumonia among new users of ICS relative to inhaled long-acting bronchodilator (LABD) monotherapy. METHODS Pneumonia events in COPD patients ≥45 years old were compared among new users of ICS medications (n = 11,555; ICS, ICS/long-acting β2-agonist [LABA] combination) and inhaled LABD monotherapies (n = 6,492; LABA, long-acting muscarinic antagonists) using Cox proportional hazards models, with propensity scores to adjust for confounding. SETTING United Kingdom electronic medical records with linked hospitalization and mortality data (2002-2010). New users were censored at earliest of: pneumonia event, death, changing/discontinuing treatment, or end of follow-up. OUTCOMES severe pneumonia (primary) and any pneumonia (secondary). RESULTS Following adjustment, new use of ICS-containing medications was associated with an increased risk of pneumonia hospitalization (n = 322 events; HR = 1.55, 95% CI: 1.14, 2.10) and any pneumonia (n = 702 events; HR = 1.49, 95% CI: 1.22, 1.83). Crude incidence rates of any pneumonia were 48.7 and 30.9 per 1000 person years among the ICS-containing and LABD cohorts, respectively. Excess risk of pneumonia with ICS was reduced when requiring ≥1 month or ≥ 6 months of new use. There was an apparent dose-related effect, with greater risk at higher daily doses of ICS. There was evidence of channeling bias, with more severe patients prescribed ICS, for which the analysis may not have completely adjusted. CONCLUSIONS The results of this new-user cohort study are consistent with published findings; ICS were associated with a 20-50% increased risk of pneumonia in COPD, which reduced with exposure time. This risk must be weighed against the benefits when prescribing ICS to patients with COPD.
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Affiliation(s)
- Rachael L. DiSantostefano
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Tim Sampson
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Hoa Van Le
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - David Hinds
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Kourtney J. Davis
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Nawar Diar Bakerly
- Salford Royal NHS Foundation Trust and Manchester University, Manchester, United Kingdom
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Martinez CH, Moy ML, Nguyen HQ, Cohen M, Kadri R, Roman P, Holleman RG, Kim HM, Goodrich DE, Giardino ND, Richardson CR. Taking Healthy Steps: rationale, design and baseline characteristics of a randomized trial of a pedometer-based Internet-mediated walking program in veterans with chronic obstructive pulmonary disease. BMC Pulm Med 2014; 14:12. [PMID: 24491137 PMCID: PMC3946238 DOI: 10.1186/1471-2466-14-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/29/2014] [Indexed: 01/24/2023] Open
Abstract
Background Low levels of physical activity are common in patients with chronic obstructive pulmonary disease (COPD), and a sedentary lifestyle is associated with poor outcomes including increased mortality, frequent hospitalizations, and poor health-related quality of life. Internet-mediated physical activity interventions may increase physical activity and improve health outcomes in persons with COPD. Methods/Design This manuscript describes the design and rationale of a randomized controlled trial that tests the effectiveness of Taking Healthy Steps, an Internet-mediated walking program for Veterans with COPD. Taking Healthy Steps includes an uploading pedometer, a website, and an online community. Eligible and consented patients wear a pedometer to obtain one week of baseline data and then are randomized on a 2:1 ratio to Taking Healthy Steps or to a wait list control. The intervention arm receives iterative step-count feedback; individualized step-count goals, motivational and informational messages, and access to an online community. Wait list controls are notified that they are enrolled, but that their intervention will start in one year; however, they keep the pedometer and have access to a static webpage. Discussion Participants include 239 Veterans (mean age 66.7 years, 93.7% male) with 155 randomized to Taking Healthy Steps and 84 to the wait list control arm; rural-living (45.2%); ever-smokers (93.3%); and current smokers (25.1%). Baseline mean St. George’s Respiratory Questionnaire Total Score was 46.0; 30.5% reported severe dyspnea; and the average number of comorbid conditions was 4.9. Mean baseline daily step counts was 3497 (+/- 2220). Veterans with COPD can be recruited to participate in an online walking program. We successfully recruited a cohort of older Veterans with a significant level of disability including Veterans who live in rural areas using a remote national recruitment strategy. Trial registration Clinical Trials.gov NCT01102777
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Caroline R Richardson
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, 48105 Ann Arbor, MI, USA.
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Ryan M, Suaya JA, Chapman JD, Stason WB, Shepard DS, Parks Thomas C. Incidence and cost of pneumonia in older adults with COPD in the United States. PLoS One 2013; 8:e75887. [PMID: 24130749 PMCID: PMC3794002 DOI: 10.1371/journal.pone.0075887] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 08/21/2013] [Indexed: 11/19/2022] Open
Abstract
Objectives To estimate the incidence of pneumonia by COPD status and the excess cost of inpatient primary pneumonia in elders with COPD. Study Design A retrospective, longitudinal study using claims linked to eligibility/demographic data for a 5% sample of fee-for-service Medicare beneficiaries from 2005 through 2007. Methods Incidence rates of pneumonia were calculated for elders with and without COPD and for elders with COPD and coexistent congestive heart failure (CHF). Propensity-score matching with multivariate generalized linear regression was used to estimate the excess direct medical cost of inpatient primary pneumonia in elders with COPD as compared with elders with COPD but without a pneumonia hospitalization. Results Elders with COPD had nearly six-times the incidence of pneumonia compared with elders without COPD (167.6/1000 person-years versus 29.5/1000 person-years; RR=5.7, p <0 .01); RR increased to 8.1 for elders with COPD and CHF compared with elders without COPD. The incidence of inpatient primary pneumonia among elders with COPD was 54.2/1000 person-years compared with 7/1000 person-years for elders without COPD; RR=7.7, p<0.01); RR increased to 11.0 for elders with COPD and CHF compared with elders without COPD. The one-year excess direct medical cost of inpatient pneumonia in COPD patients was $ 22,697 ($45,456 in cases vs. $ 22,759 in controls (p <0.01)); 70.2% of this cost was accrued during the quarter of the index hospitalization. During months 13 through 24 following the index hospitalization, the excess direct medical cost was $ 5,941 ($23,215 in cases vs. $ 17,274 in controls, p<0.01). Conclusions Pneumonia occurs more frequently in elders with COPD than without COPD. The excess direct medical cost in elders with inpatient pneumonia extends up to 24 months following the index hospitalization and represents $28,638 in 2010 dollars.
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Affiliation(s)
- Marian Ryan
- Brandeis University, Schneider Institute on Healthcare Systems, Heller School, Waltham, Massachusetts, United States of America
- * E-mail:
| | - Jose A. Suaya
- GlaxoSmithKline Vaccines, Philadelphia, Pennsylvania, United States of America
| | - John D. Chapman
- Brandeis University, Schneider Institute on Healthcare Systems, Heller School, Waltham, Massachusetts, United States of America
| | - William B. Stason
- Brandeis University, Schneider Institute on Healthcare Systems, Heller School, Waltham, Massachusetts, United States of America
| | - Donald S. Shepard
- Brandeis University, Schneider Institute on Healthcare Systems, Heller School, Waltham, Massachusetts, United States of America
| | - Cindy Parks Thomas
- Brandeis University, Schneider Institute on Healthcare Systems, Heller School, Waltham, Massachusetts, United States of America
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Abstract
In healthy individuals, billions of cells die by apoptosis each day. Clearance of these apoptotic cells, termed "efferocytosis," must be efficient to prevent secondary necrosis and the release of proinflammatory cell contents that disrupt tissue homeostasis and potentially foster autoimmunity. During inflammation, most apoptotic cells are cleared by macrophages; the efferocytic process actively induces a macrophage phenotype that favors tissue repair and suppression of inflammation. Several chronic lung diseases, particularly airways diseases such as chronic obstructive lung disease, asthma, and cystic fibrosis, are characterized by an increased lung burden of uningested apoptotic cells. Alveolar macrophages from individuals with these chronic airways diseases have decreased efferocytosis relative to alveolar macrophages from healthy subjects. These two findings have led to the hypothesis that impaired apoptotic cell clearance may contribute causally to sustained lung inflammation and that therapies to enhance efferocytosis might be beneficial. This review of the English-language scientific literature (2006 to mid-2012) explains how such existing therapies as corticosteroids, statins, and macrolides may act in part by augmenting apoptotic cell clearance. However, efferocytosis can also impede host defenses against lung infection. Thus, determining whether novel therapies to augment efferocytosis should be developed and in whom they should be used lies at the heart of efforts to differentiate specific phenotypes within complex chronic lung diseases to provide appropriately personalized therapies.
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Affiliation(s)
| | - Jeffrey L Curtis
- Graduate Program in Immunology, VA Ann Arbor Healthcare System, Ann Arbor, MI; Division of Pulmonary and Critical Care Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Health System; and the Pulmonary and Critical Care Medicine Section, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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Eurich DT, Lee C, Marrie TJ, Majumdar SR. Inhaled Corticosteroids and Risk of Recurrent Pneumonia: A Population-Based, Nested Case-Control Study. Clin Infect Dis 2013; 57:1138-44. [DOI: 10.1093/cid/cit472] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Yawn BP, Li Y, Tian H, Zhang J, Arcona S, Kahler KH. Inhaled corticosteroid use in patients with chronic obstructive pulmonary disease and the risk of pneumonia: a retrospective claims data analysis. Int J Chron Obstruct Pulmon Dis 2013; 8:295-304. [PMID: 23836970 PMCID: PMC3699136 DOI: 10.2147/copd.s42366] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The use of inhaled corticosteroids in patients with chronic obstructive pulmonary disease (COPD) has been associated with an increased risk of pneumonia in controlled clinical trials and case-control analyses. OBJECTIVE Using claims databases as a research model of real-world diagnosis and treatment, to determine if the use and dose of inhaled corticosteroids (ICS) among patients with newly diagnosed COPD are associated with increased risk of pneumonia. PATIENTS AND METHODS This was a retrospective cohort analysis of patients diagnosed with COPD between January 01, 2006 and September 30, 2010, drawn from databases (years 2006-2010). Patients (aged ≥45 years) were followed until first pneumonia diagnosis, end of benefit enrollment, or December 31, 2010, whichever was earliest. A Cox proportional hazard model was used to assess the association of ICS use and risk of pneumonia, controlling for baseline characteristics. Daily ICS use was classified into low, medium, and high doses (1 μg-499 μg, 500 μg-999 μg, and ≥1000 μg fluticasone equivalents daily) and was modeled as a time-dependent variable. RESULTS Among 135,445 qualifying patients with a total of 243,097 person-years, there were 1020 pneumonia incidences out of 5677 person-years on ICS (crude incidence rate, 0.180 per person-year), and 27,730 pneumonia incidences out of 237,420 person-years not on ICS (crude incidence rate, 0.117 per person-year). ICS use was associated with a dose-related increase in risk of pneumonia, with adjusted hazard ratios (versus no use; (95% confidence interval) of 1.38 (1.27-1.49) for low-dose users, 1.69 (1.52-1.88) for medium-dose users, and 2.57 (1.98-3.33) for high-dose users (P < 0.01 versus no use and between doses). CONCLUSION The use of ICS in newly diagnosed patients with COPD is potentially associated with a dose-related increase in the risk of pneumonia.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN 55904, USA.
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Loke YK, Kwok CS, Wong JM, Sankaran P, Myint PK. Chronic obstructive pulmonary disease and mortality from pneumonia: meta-analysis. Int J Clin Pract 2013; 67:477-87. [PMID: 23574107 DOI: 10.1111/ijcp.12120] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/27/2012] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND We aimed to determine whether patients with concomitant community-acquired pneumonia (CAP) and chronic obstructive pulmonary disease (COPD) are at greater risk of death when compared with those with CAP or acute COPD exacerbation alone. We also assessed the effect of inhaled corticosteroids (ICS) on pneumonia mortality in COPD. METHODS We searched MEDLINE and EMBASE from inception to March 2012 for studies reporting on mortality in patients with COPD and CAP. We assessed ascertainment of disease, mortality, drug exposure and adjustment for confounders. Data were pooled using random effects meta-analysis, and heterogeneity was estimated using I². RESULTS We identified 24 eligible articles overall. Evaluation of 13 studies revealed considerable heterogeneity and a non-significant mortality risk associated with concomitant COPD and CAP as compared with CAP in five studies that reported adjusted or severity-matched data, pooled RR 1.44 (95% CI 0.97-2.16, I² = 50%). There was also considerable inconsistency amongst the effect estimates from five studies that reported on the associated mortality with concomitant CAP and COPD as compared with acute COPD exacerbations alone. Evaluation of six datasets found that ICS use in COPD was not consistently associated with lower mortality in CAP. Reports of reduced mortality with prior ICS use stemmed from three studies that enrolled participants from the same healthcare database. CONCLUSIONS Evidence on associated mortality risk with concomitant CAP and COPD (as opposed to CAP alone, or COPD exacerbation alone) is weak and heterogeneous. ICS use was not consistently associated with reduced mortality from pneumonia.
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Affiliation(s)
- Y K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK.
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A Novel Anti-Inflammatory and Pro-Resolving Role for Resolvin D1 in Acute Cigarette Smoke-Induced Lung Inflammation. PLoS One 2013; 8:e58258. [PMID: 23484005 PMCID: PMC3590122 DOI: 10.1371/journal.pone.0058258] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 02/01/2013] [Indexed: 12/21/2022] Open
Abstract
Introduction Cigarette smoke is a profound pro-inflammatory stimulus that contributes to acute lung injuries and to chronic lung disease including COPD (emphysema and chronic bronchitis). Until recently, it was assumed that resolution of inflammation was a passive process that occurred once the inflammatory stimulus was removed. It is now recognized that resolution of inflammation is a bioactive process, mediated by specialized lipid mediators, and that normal homeostasis is maintained by a balance between pro-inflammatory and pro-resolving pathways. These novel small lipid mediators, including the resolvins, protectins and maresins, are bioactive products mainly derived from dietary omega-3 and omega-6 polyunsaturated fatty acids (PUFA). We hypothesize that resolvin D1 (RvD1) has potent anti-inflammatory and pro-resolving effects in a model of cigarette smoke-induced lung inflammation. Methods Primary human lung fibroblasts, small airway epithelial cells and blood monocytes were treated with IL-1β or cigarette smoke extract in combination with RvD1 in vitro, production of pro-inflammatory mediators was measured. Mice were exposed to dilute mainstream cigarette smoke and treated with RvD1 either concurrently with smoke or after smoking cessation. The effects on lung inflammation and lung macrophage populations were assessed. Results RvD1 suppressed production of pro-inflammatory mediators by primary human cells in a dose-dependent manner. Treatment of mice with RvD1 concurrently with cigarette smoke exposure significantly reduced neutrophilic lung inflammation and production of pro-inflammatory cytokines, while upregulating the anti-inflammatory cytokine IL-10. RvD1 promoted differentiation of alternatively activated (M2) macrophages and neutrophil efferocytosis. RvD1 also accelerated the resolution of lung inflammation when given after the final smoke exposure. Conclusions RvD1 has potent anti-inflammatory and pro-resolving effects in cells and mice exposed to cigarette smoke. Resolvins have strong potential as a novel therapeutic approach to resolve lung injury caused by smoke and pulmonary toxicants.
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Price D, Yawn B, Brusselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:92-100. [PMID: 23135217 PMCID: PMC6548052 DOI: 10.4104/pcrj.2012.00092] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/20/2012] [Accepted: 09/20/2012] [Indexed: 11/08/2022]
Abstract
While the pharmacological management of chronic obstructive pulmonary disease (COPD) has evolved from the drugs used to treat asthma, the treatment models are different and the two diseases require clear differential diagnosis in order to determine the correct therapeutic strategy. In contrast to the almost universal requirement for anti-inflammatory treatment of persistent asthma, the efficacy of inhaled corticosteroids (ICS) is less well established in COPD and their role in treatment is limited. There is some evidence of a preventive effect of ICS on exacerbations in patients with COPD, but there is little evidence for an effect on mortality or lung function decline. As a result, treatment guidelines recommend the use of ICS in patients with severe or very severe disease (forced expiratory volume in 1 second <50% predicted) and repeated exacerbations. Patients with frequent exacerbations - a phenotype that is stable over time - are likely to be less common among those with moderate COPD (many of whom are managed in primary care) than in those with more severe disease. The indiscriminate use of ICS in COPD may expose patients to an unnecessary increase in the risk of side-effects such as pneumonia, osteoporosis, diabetes and cataracts, while wasting healthcare spending and potentially diverting attention from other more appropriate forms of management such as pulmonary rehabilitation and maximal bronchodilator use. Physicians should carefully weigh the likely benefits of ICS use against the potential risk of side-effects and costs in individual patients with COPD.
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Affiliation(s)
- David Price
- Primary Care Respiratory Society UK Professor of Primary Care Respiratory Medicine, University of Aberdeen, UK.
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Marzoratti L, Iannella HA, Waterer GW. Inhaled corticosteroids and the increased risk of pneumonia. Ther Adv Respir Dis 2013; 7:225-34. [PMID: 23445751 DOI: 10.1177/1753465813480550] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Recently it has been suggested that there is a causal association between the use of inhaled corticosteroids (ICSs) and the risk of developing pneumonia in patients with chronic obstructive pulmonary disease (COPD). An increased risk of pneumonia associated with ICS use has been seen in trials with different design, different study populations and with evidence of a dose-response relationship. However, as none of these clinical trials were originally designed to assess pneumonia risk, radiographic confirmation of pneumonia was not always obtained. The extent to which pneumonia events have been confounded with acute exacerbations of COPD is unclear. As increased pneumonia events were not associated with increased mortality it remains unclear what the clinical significance of these findings are. Further complicating the association between ICSs and pneumonia is that meta-analyses restricted to budesonide trials have not shown an increased risk of pneumonia, and no association has been seen in patients with asthma. A number of mechanisms by which ICSs could increase the risk of pneumonia have been proposed, principally related to their immunosuppressive effect. Well-designed clinical trials with predefined endpoints and objective pneumonia definitions are needed before the real risk of pneumonia conferred by ICSs can be established. In the meantime, it seems reasonable to reduce ICSs given to COPD patients to the lowest effective doses, reduce the risk in individual patients by ensuring appropriate vaccination and to be vigilant for the possibility of pneumonia in patients with COPD on ICSs as they largely overlap with those of an acute exacerbation.
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Affiliation(s)
- Lucía Marzoratti
- CEMIT (Centro Médico Investigadores Tucumán), San Miguel de Tucumán, Tucumán, Argentina
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Topal AE, Eren MN. Risk factors for the development of pneumonia post cardiac surgery. Cardiovasc J Afr 2013; 23:212-5. [PMID: 22614666 PMCID: PMC3721923 DOI: 10.5830/cvja-2012-005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 01/17/2012] [Indexed: 11/16/2022] Open
Abstract
Objectives Postoperative pneumonia is a devastating complication after cardiac surgery that increases morbidity and mortality. The objective of this study was to identify potential risk factors for the development of nosocomial pneumonia post cardiac surgery by the way of logistic regression analysis. Design Data of the last 162 patients undergoing cardiac surgery before November 2009 were retrospectively collected and analysed. Results The mean age of the patients was 65.57 ± 10.48 years and 83 (51%) were male. Postoperative pneumonia was diagnosed in 21 (13%) patients. The mean remaining time in the intensive care unit and mean length of hospitalisation were longer for patients with postoperative pneumonia. Pre-operative heart rate, previous diabetes mellitus, previous chronic obstructive pulmonary disease, postoperative urea, creatinine and potassium levels, extubation time, postoperative atrial fibrillation, and number of units of transfused packed red blood cells (pRBC) and fresh frozen plasma were associated with higher occurrence of postoperative pneumonia on univariate analysis. Conclusions On logistic regression analysis, pRBC transfusion, previous chronic obstructive pulmonary disease and postoperative atrial fibrillation remained as independent predictors for the development of postoperative pneumonia.
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Affiliation(s)
- A E Topal
- Cardiovascular Surgery Department, Dicle University Medical Faculty, Diyarbakir,Turkey.
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Thornton Snider J, Luna Y, Wong KS, Zhang J, Chen SS, Gless PJ, Goldman DP. Inhaled corticosteroids and the risk of pneumonia in Medicare patients with COPD. Curr Med Res Opin 2012; 28:1959-67. [PMID: 23098081 DOI: 10.1185/03007995.2012.743459] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the association between inhaled corticosteroid (ICS) use and the risk of pneumonia among Medicare patients with chronic obstructive pulmonary disease (COPD). METHODS A nested case control analysis was performed to study the relationship between ICS use and pneumonia risk in a cohort of Medicare Advantage members with COPD. Patients were identified through a medical and pharmacy claims database. A case was designated as patient's first inpatient or outpatient pneumonia episode. Cases were matched to controls who entered the COPD cohort at the same time, but had not yet developed pneumonia by the case's index date. The association between ICS use and pneumonia was estimated using logistic regression. Adjusted models controlled for age, sex, race, use of other COPD medications, markers of COPD severity, receipt of the pneumococcal vaccine, and comorbidities. Analyses were also stratified by current or past ICS use, as well as dosage (low, medium, or high). RESULTS Out of a COPD cohort of 83,455 members, 13,778 pneumonia episodes were identified; these cases were matched to 36,767 controls. Adjusting for covariates, having used any ICS during the past year was associated with increased risk of a pneumonia episode (OR 1.11, 95% CI: 1.05-1.18). Pneumonia risk was highest for current ICS users (OR 1.26, 95% CI: 1.16-1.36) and current high-dose users (OR 1.55, 95% CI: 1.25-1.92), compared to non-users. CONCLUSION As a retrospective claims analysis, this study had inherent limitations. The pneumonia diagnosis could not be confirmed, smoking history and other health confounders were not included. However, given the large study sample size and extensive number of available controls, the results remain persuasive and confirm previous studies' findings that ICS use, particularly current use and high-dose use, is associated with increased pneumonia risk.
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Yawn BP. Is 'GOLD' standard for the management of COPD in clinical practice? Drugs Context 2012; 2012:212243. [PMID: 24432032 PMCID: PMC3884956 DOI: 10.7573/dic.212243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 09/14/2012] [Indexed: 12/29/2022] Open
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Müllerova H, Chigbo C, Hagan GW, Woodhead MA, Miravitlles M, Davis KJ, Wedzicha JA. The natural history of community-acquired pneumonia in COPD patients: a population database analysis. Respir Med 2012; 106:1124-33. [PMID: 22621820 DOI: 10.1016/j.rmed.2012.04.008] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 04/06/2012] [Accepted: 04/23/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients with Chronic Obstructive Pulmonary Disease (COPD) are at higher risk of developing Community-Acquired Pneumonia (CAP) than patients in the general population. However, no studies have been performed in general practice assessing longitudinal incidence rates for CAP in COPD patients or risk factors for pneumonia onset. METHODS A cohort of COPD patients aged ≥ 45 years, was identified in the General Research Practice Database (GPRD) between 1996 and 2005, and annual and 10-year incidence rates of CAP evaluated. A nested case-control analysis was performed, comparing descriptors in COPD patients with and without CAP using conditional logistic regression generating odds ratios (OR) and 95% confidence intervals (CI). RESULTS The COPD cohort consisted of 40,414 adults. During the observation period, 3149 patients (8%) experienced CAP, producing an incidence rate of 22.4 (95% CI 21.7-23.2) per 1000 person years. 92% of patients with pneumonia diagnosis had suffered only one episode. Multivariate modelling of pneumonia descriptors in COPD indicate that age over 65 years was significantly associated with increased risk of CAP. Other independent risk factors associated with CAP were co-morbidities including congestive heart failure (OR 1.4, 95% CI 1.2-1.6), and dementia (OR 2.6, 95%CI 1.9-3.). Prior severe COPD exacerbations requiring hospitalization (OR 2.7, 95% CI 2.3-3.2) and severe COPD requiring home oxygen or nebulised therapy (OR 1.4, 95% CI 1.1-1.6) were also significantly associated with risk of CAP. CONCLUSION COPD patients presenting in general practice with specific co-morbidities, severe COPD, and age >65 years are at increased risk of CAP.
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Affiliation(s)
- Hana Müllerova
- Worldwide Epidemiology, GlaxoSmithKline Research and Development, Building 9, Iron Bridge Road, Stockley Park West, Uxbridge, Middlesex UB11 1BT, UK.
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Joo MJ, Au DH, Fitzgibbon ML, McKell J, Lee TA. Determinants of spirometry use and accuracy of COPD diagnosis in primary care. J Gen Intern Med 2011; 26:1272-7. [PMID: 21713542 PMCID: PMC3208468 DOI: 10.1007/s11606-011-1770-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 06/03/2011] [Accepted: 06/04/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unclear if primary care physicians are following guidelines or using other patient characteristics and factors to determine when to perform spirometry in patients at risk for COPD. It is also unclear to what degree a diagnosis of COPD is accurately reflected by spirometry results. OBJECTIVES To examine characteristics associated with use of spirometry in primary care for patients with increased risk for COPD and to determine the accuracy of COPD diagnosis in patients with spirometry. DESIGN Retrospective cohort study. SUBJECTS A cohort that met the following criteria was identified: ≥35 years of age; ≥ 2 primary care visits in internal medicine clinic in 2007; at least one respiratory or smoking cessation medication, or diagnosis of COPD or shortness of breath or dyspnea in 2007. MAIN MEASURES Medical records of all primary care physician visits prior to the time of inclusion in 2007 were reviewed. Data on patient demographics, co-morbidities, respiratory medication use, presence of symptoms, history of tobacco use, and pulmonary function tests were extracted. KEY RESULTS A total 1052 patients were identified. Dyspnea on exertion (Adjusted odds ratio (AOR) 1.52 [95% CI 1.06-2.18]) and chronic cough (AOR 1.71 [1.07-2.72]) were the only chronic symptoms associated with use of spirometry. Current (AOR 1.54 [0.99-2.40]) or past smoking (AOR 1.09 [0.72-1.65]) status were not associated with use of spirometry. Of the 159 patients with a diagnosis of COPD, 93 (58.5%) met GOLD criteria and 81(50.9%) met lower limit of normal (LLN) criteria for COPD. CONCLUSION Clinicians use spirometry more often among patients with symptoms suggestive of COPD but not more often among patients with current or past tobacco use. For patients who had a spirometry and a diagnosis of COPD, primary care physicians were accurate in their diagnosis only half of the time.
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Affiliation(s)
- Min J Joo
- Section of Pulmonary, Critical Care, Sleep and Allergy Medicine, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA.
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Cheng SL, Wang HC, Cheng SJ, Yu CJ. Elevated placenta growth factor predicts pneumonia in patients with chronic obstructive pulmonary disease under inhaled corticosteroids therapy. BMC Pulm Med 2011; 11:46. [PMID: 21962211 PMCID: PMC3195784 DOI: 10.1186/1471-2466-11-46] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 09/30/2011] [Indexed: 02/07/2023] Open
Abstract
Background An increased incidence of pneumonia in patients with chronic obstructive pulmonary disease (COPD) under inhaled corticosteroid (ICS) therapy was noticed in previous studies. We performed a prospective study to elucidate the risk factors for the development of pneumonia in this group of patients. Methods A prospective, non-randomized study with patients diagnosed as having COPD from 2007 to 2008 identified in the Far Eastern Memorial Hospital were recruited. We recorded data for all patients, including clinical features and signs, demographic data, lung function status, and medications. Bio-markers such as C-reactive protein (CRP) and placenta growth factor (PlGF) were checked at first diagnosis. Every acute exacerbation was also recorded, especially pneumonia events, which were confirmed by chest radiography. Multivariate analysis was performed with stepwise logistic regression for pneumonia risk factors. Results 274 patients were diagnosed as having COPD during the study period and 29 patients suffered from pneumonia with a prevalence of 10.6%. The rate was significantly higher in patients with ICS therapy (20/125, 16%) compared with those without ICS (9/149, 6%) (p = 0.02). We stratified ICS therapy into medium dose (500-999 ug/day fluticasone equivalent, 71 patients) and high dose (1000 ug/day and higher fluticasone equivalent, 54 patients) group. There was no statistical difference in the incidence of pneumonia between these two group (medium dose: 13/71, 18.3% vs. high dose: 7/54, 12.9%, p = 0.47). Multivariate analysis was performed to identify the risk factors for developing pneumonia and included forced expiratory volume in one second (FEV1) less than 40% of predicted (odds ratio (OR) 2.2, 95% confidence interval (CI): 1.1-6.9), ICS prescription ((OR) 2.4, 95% (CI): 1.3-8.7), the presence of diabetes mellitus (DM) (OR 2.6, 95% CI: 1.2-9.4) and PlGF level over 40 pg/L (OR 4.1, 95% CI: 1.5-9.9). Conclusion ICS therapy in patients with COPD increased the risk of pneumonia. However, there was no relationship between the incidence of pneumonia and dosage of ICS. Additionally, advanced COPD status, DM and elevated PlGF level were independent risk factors for the development of pneumonia. PlGF would be a good novel biomarker for predicting pneumonia.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Pan-Chiao, Taipei, Taiwan
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