Corticosteroids in chronic obstructive pulmonary disease. Clinical benefits and risks

Use of inhaled corticosteroids and the risk of developing type 2 diabetes in patients with chronic obstructive pulmonary disease

AIM

To determine the risk of type 2 diabetes onset associated with accumulated inhaled corticosteroids (ICS) dose during the previous year in patients with chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

We conducted a nationwide observational cohort study based on data from patients with COPD between 1 January 2010 and 31 December 2017 extracted from Danish health databases. Patients were followed for 7 years, until death or a type 2 diabetes event. A propensity-matched Cox model and an adjusted Cox proportional hazards model (stratified on body mass index [BMI]) were used to estimate the hazard ratio (HR) for new-onset type 2 diabetes.

RESULTS

A total of 50 148 patients with COPD were included, 3566 (7.1%) of whom had a type 2 diabetes event. During the previous year before study entry, 35 368 patients (70.5%) used ICS. The propensity-matched Cox model (N = 33 466) showed an increased risk of type 2 diabetes, which progressed with increasing accumulated ICS dose (low-ICS: HR 1.076, confidence interval [CI] 1.075-1.077, P < .0001; medium-ICS: HR 1.106, CI 1.105-1.108, P < .0001; high-ICS: HR 1.150, CI 1.148-1.151, P < .0001), compared with no ICS use. Results were confirmed in the adjusted Cox analysis on the entire study population, but only for patients with BMI <30 kg/m² .

CONCLUSIONS

In patients with COPD, ICS use was associated with a moderate dose-dependent increase in the occurrence of type 2 diabetes.

Allogeneic umbilical cord-derived mesenchymal stem cell transplantation for treating chronic obstructive pulmonary disease: a pilot clinical study

Introduction

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. COPD results from chronic inflammation of the lungs. Current treatments, including physical and chemical therapies, provide limited results. Stem cells, particularly mesenchymal stem cells (MSCs), are used to treat COPD. Here, we evaluated the safety and efficacy of umbilical cord-derived (UC)-MSCs for treating COPD.

Methods

Twenty patients were enrolled, 9 at stage C and 11 at stage D per the Global Initiative for Obstructive Lung Disease (GOLD) classification. Patients were infused with 10⁶ cells/kg of expanded allogeneic UC-MSCs. All patients were followed for 6 months after the first infusion. The treatment end-point included a comprehensive safety evaluation, pulmonary function testing (PFT), and quality-of-life indicators including questionnaires, the 6-min walk test (6MWT), and systemic inflammation assessments. All patients completed the full infusion and 6-month follow-up.

Results

No infusion-related toxicities, deaths, or severe adverse events occurred that were deemed related to UC-MSC administration. The UC-MSC-transplanted patients showed a significantly reduced Modified Medical Research Council score, COPD assessment test, and number of exacerbations. However, the forced expiratory volume in 1 s, C-reactive protein, and 6MWT values were nonsignificantly reduced after treatment (1, 3, and 6 months) compared with those before the treatment.

Conclusion

Systemic UC-MSC administration appears to be safe in patients with moderate-to-severe COPD, can significantly improve their quality of life, and provides a basis for subsequent cell therapy investigations.

Trial registration

ISRCTN, ISRCTN70443938. Registered 06 July 2019

COPD exacerbations: the impact of long versus short courses of oral corticosteroids on mortality and pneumonia: nationwide data on 67 000 patients with COPD followed for 12 months

Introduction

A large group of patients with chronic obstructive pulmonary disease (COPD) are exposed to an overload of oral corticosteroids (OCS) due to repeated exacerbations. This is associated with potential serious adverse effects. Therefore, we evaluated the impact of a recommended reduction of OCS duration in 2014 on the risk of pneumonia hospitalisation and all-cause mortality in patients with acute exacerbation of COPD (AECOPD).

Methods

This was a nationwide observational cohort study that was based on linked administrative registry data between 1 January 2010 and 31 October 2017. 10 152 outpatients with COPD (median age 70 years) treated with either a short (≤250 mg) or long course (>250 mg) of OCS for AECOPD were included in the study. Cox proportional hazards regression models were used to derive an estimation of multivariable adjusted HRs (aHRs) for pneumonia hospitalisation or all-cause mortality combined and pneumonia hospitalisation and all-cause mortality, separately.

Results

The long course of OCS treatment for AECOPD was associated with an increased 1-year risk of pneumonia hospitalisation or all-cause mortality (aHR 1.3, 95% CI 1.1 to 1.4; p<0.0001), pneumonia hospitalisation (aHR 1.2, 95% CI 1.0 to 1.3; p=0.0110) and all-cause mortality (aHR 1.8, 95% CI 1.5 to 2.2; p<0.0001) as compared with the short course of OCS treatment. These results were confirmed in several sensitivity analyses.

Conclusion

The change of recommendations from long courses to short courses of OCS for AECOPD in 2014 was strongly associated with a decrease in pneumonia admissions and all-cause mortality, in favour of short courses of OCS.

Intensive care and invasive ventilation in the elderly patient, implications of chronic lung disease and comorbidities

Aims: Elderly patients have an increasing prevalence of illness that requires consideration of critical care and invasive ventilatory support. Although critical care of even the very elderly can provide value, with increasing age the potential risks of treatment and diminishing returns with respect to quality and quantity of life result in a need for careful evaluation. Variable combinations of impaired organ function, active disease and residual pathology from past disease and injury all affect critical care, with the consequence that the elderly are a very heterogeneous population. Recognizing that critical care is a limited resource, it is important to identify patients who may be at increased risk or least likely to benefit from treatment. Patients with functional impairments, nutritional deficiencies and multiple comorbidities may be at highest risk of poor outcomes. Those with very severe disease, extreme age and requirements for prolonged ventilatory support have high in-hospital mortality. Functional impairments, comorbidities and severity of illness are usually more important considerations than chronologic age. The objective of this review is to identify how common problems of the elderly affect critical care and decisions concerning use of invasive ventilatory support.

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children

BACKGROUND

People with asthma may experience exacerbations or "attacks" during which their symptoms worsen and additional treatment is required. Written action plans may advocate doubling the dose of inhaled steroids in the early stages of an asthma exacerbation to reduce the severity of the attack and to prevent the need for oral steroids or hospital admission.

OBJECTIVES

To compare the clinical effectiveness and safety of increased versus stable doses of inhaled corticosteroids (ICS) as part of a patient-initiated action plan for home management of exacerbations in children and adults with persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register, which is derived from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to March 2016. We handsearched respiratory journals and meeting abstracts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared increased versus stable doses of ICS for home management of asthma exacerbations. We included studies of children or adults with persistent asthma who were receiving daily maintenance ICS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information.

MAIN RESULTS

This review update added three new studies including 419 participants to the review. In total, we identified eight RCTs, most of which were at low risk of bias, involving 1669 participants with mild to moderate asthma. We included three paediatric (n = 422) and five adult (n = 1247) studies; six were parallel-group trials and two had a cross-over design. All but one study followed participants for six months to one year. Allowed maintenance doses of ICS varied in adult and paediatric studies, as did use of concomitant medications and doses of ICS initiated during exacerbations. Investigators gave participants a study inhaler containing additional ICS or placebo to be started as part of an action plan for treatment of exacerbations.The odds of treatment failure, defined as the need for oral corticosteroids, were not significantly reduced among those randomised to increased ICS compared with those taking their usual stable maintenance dose (odds ratio (OR) 0.89, 95% confidence interval (CI) 0.68 to 1.18; participants = 1520; studies = 7). When we analysed only people who actually took their study inhaler for an exacerbation, we found much variation between study results but the evidence did not show a significant benefit of increasing ICS dose (OR 0.84, 95% CI 0.54 to 1.30; participants = 766; studies = 7). The odds of having an unscheduled physician visit (OR 0.96, 95% CI 0.66 to 1.41; participants = 931; studies = 3) or acute visit (Peto OR 0.98, 95% CI 0.24 to 3.98; participants = 450; studies = 3) were not significantly reduced by an increased versus stable dose of ICS, and evidence was insufficient to permit assessment of impact on the duration of exacerbation; our ability to draw conclusions from these outcomes was limited by the number of studies reporting these events and by the number of events included in the analyses. The odds of serious events (OR 1.69, 95% CI 0.77 to 3.71; participants = 394; studies = 2) and non-serious events, such as oral irritation, headaches and changes in appetite (OR 2.15, 95% CI 0.68 to 6.73; participants = 142; studies = 2), were neither increased nor decreased significantly by increased versus stable doses of ICS during an exacerbation. Too few studies are available to allow firm conclusions on the basis of subgroup analyses conducted to investigate the impact of age, time to treatment initiation, doses used, smoking history and the fold increase of ICS on the magnitude of effect; yet, effect size appears similar in children and adults.

AUTHORS' CONCLUSIONS

Current evidence does not support increasing the dose of ICS as part of a self initiated action plan to treat exacerbations in adults and children with mild to moderate asthma. Increased ICS dose is not associated with a statistically significant reduction in the odds of requiring rescue oral corticosteroids for the exacerbation, or of having adverse events, compared with a stable ICS dose. Wide confidence intervals for several outcomes mean we cannot rule out possible benefits of this approach.

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children

BACKGROUND

Written action plans providing guidance in the early treatment of asthma exacerbations have traditionally advocated doubling of inhaled corticosteroids (ICS) as one of the first steps in treatment.

OBJECTIVES

To compare the clinical effectiveness of increasing the dose of ICS versus keeping the usual maintenance dose as part of a patient-initiated action plan at the onset of asthma exacerbations.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (last search October 2009) which is derived from searches of CENTRAL, MEDLINE, EMBASE and CINAHL, as well as handsearched respiratory journals and meeting abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the strategy of increasing the daily dose of ICS to continuing the same ICS dose in the home management of asthma exacerbations in children or adults with persistent asthma on daily maintenance ICS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information.

MAIN RESULTS

Five RCTs (four parallel-group and one cross-over) involving a total of 1250 patients (28 children and 1222 adults) with mild to moderate asthma were included. The mean daily baseline ICS dose was 555 mcg (range 200 mcg to 795 mcg) and the mean daily ICS dose achieved following increase was 1520 mcg (range 1000 mcg to 2075 mcg), in CFC beclomethasone dipropionate equivalents. Three parallel-group studies in adults (two doubling and one quadrupling; mean achieved daily dose of 1695 mcg with a range of 1420 to 2075 mcg), involving 1080 patients contributed data to the primary outcome. There was no significant reduction in the need for rescue oral corticosteroids when patients were randomised to the increased ICS compared to stable maintenance dose groups (OR 0.85, 95% CI 0.58 to 1.26). There was no significant difference in the overall risk of non-serious adverse events associated with the increased ICS dose strategy, but the wide confidence interval prevents a firm conclusion. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is very little evidence from trials in children. In adults with asthma on daily maintenance ICS, a self-initiated ICS increase to 1000 to 2000 mcg/day at the onset of an exacerbation is not associated with a statistically significant reduction in the risk of exacerbations requiring rescue oral corticosteroids. More research is needed to assess the effectiveness of increased ICS doses at the onset of asthma exacerbations (particularly in children).

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children

BACKGROUND

Written action plans providing guidance in the early treatment of asthma exacerbations have traditionally advocated doubling of inhaled corticosteroids (ICS) as one of the first steps in treatment.

OBJECTIVES

To compare the clinical effectiveness of increasing the dose of ICS versus keeping the usual maintenance dose as part of a patient-initiated action plan at the onset of asthma exacerbations.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (last search October 2009) which is derived from searches of CENTRAL, MEDLINE, EMBASE and CINAHL, as well as handsearched respiratory journals and meeting abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the strategy of increasing the daily dose of ICS to continuing the same ICS dose in the home management of asthma exacerbations in children or adults with persistent asthma on daily maintenance ICS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information.

MAIN RESULTS

Five RCTs (four parallel-group and one cross-over) involving a total of 1250 patients (28 children and 1222 adults) with mild to moderate asthma were included. The mean daily baseline ICS dose was 555 mg (range 200 mg to 795 mg) and the mean daily ICS dose achieved following increase was 1520 mg (range 1000 mg to 2075 mg), in CFC beclomethasone dipropionate equivalents. Three parallel-group studies in adults (two doubling and one quadrupling; mean achieved daily dose of 1695 mg with a range of 1420 to 2075 mg), involving 1080 patients contributed data to the primary outcome. There was no significant reduction in the need for rescue oral corticosteroids when patients were randomised to the increased ICS compared to stable maintenance dose groups (OR 0.85, 95% CI 0.58 to 1.26). There was no significant difference in the overall risk of non-serious adverse events associated with the increased ICS dose strategy, but the wide confidence interval prevents a firm conclusion. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is very little evidence from trials in children. In adults with asthma on daily maintenance ICS, a self-initiated ICS increase to 1000 to 2000 mcg/day at the onset of an exacerbation is not associated with a statistically significant reduction in the risk of exacerbations requiring rescue oral corticosteroids. More research is needed to assess the effectiveness of increased ICS doses at the onset of asthma exacerbations (particularly in children).

The association of inhaled corticosteroid use with serum glucose concentration in a large cohort

BACKGROUND

Inhaled corticosteroids (ICSs) are widely used in the treatment of obstructive lung disease. ICSs have been shown to be systemically absorbed. The association between ICS and serum glucose concentration is unknown.

METHODS

To explore the association of ICS dosing with serum glucose concentration, we used a prospective cohort study of US veterans enrolled in 7 primary care clinics between December 1996 and May 2001 with 1 or more glucose measurements while at least 80% adherent to ICS dosing. The association between ICS dose from pharmacy records standardized to daily triamcinolone equivalents and serum glucose concentration was examined with generalized estimating equations controlling for confounders, including systemic corticosteroid use.

RESULTS

Of the 1698 subjects who met inclusion criteria, 19% had self-reported diabetes. The mean daily dose of ICS in triamcinolone equivalents was 621 microg (standard deviation 555) and 610 microg (standard deviation 553) for subjects with and without diabetes, respectively. After controlling for systemic corticosteroid use and other potential confounders, no association between ICS and serum glucose was found for subjects without diabetes. However, among subjects with self-reported diabetes, every additional 100 microg of ICS dose was associated with an increased glucose concentration of 1.82 mg/dL (P value .007; 95% confidence interval [CI], 0.49-3.15). Subjects prescribed antiglycemic medications had an increase in serum glucose of 2.65 mg/dL (P value .003; 95% CI, 0.88-4.43) for every additional 100 microg ICS dose.

CONCLUSION

Among diabetic patients, ICS use is associated with an increased serum glucose concentration in a dose-response manner.

Inhaled budesonide in the management of acute worsenings and exacerbations of asthma: a review of the evidence

The use of systemic corticosteroids, together with bronchodilators and oxygen therapy, has become established for the management of acute asthma. These agents are undoubtedly effective, but are also associated with problems such as metabolic adverse effects. Inhaled corticosteroids (ICS) offer potential benefit in the acute setting because they are delivered directly to the airways. They are also likely to reduce systemic exposure, which would lead in turn to reductions in rates of unwanted systemic effects. In order to evaluate the role of budesonide in the management of acute asthma exacerbations we conducted a review of the literature and critically evaluated the rationale for the use of ICS in general in this setting. Trials in adults and children requiring treatment for acute exacerbation of asthma have shown clinical and/or spirometric benefit for budesonide when delivered via nebulizer, dry powder inhaler, or aerosol in the emergency department, hospital and follow-up settings. The efficacy seems to benefit from high doses given repeatedly during the initial phase of an acute exacerbation. These acute effects are likely to be linked to the drug's distinctive pharmacokinetic and pharmacodynamic profile. The current evidence base revealed encouraging results regarding the efficacy of the ICS budesonide in patients with wheeze and acute worsening of asthma. Future studies should focus on the efficacy of these agents in more severe asthma worsenings.

The risk/benefit of inhaled corticosteroids in chronic obstructive pulmonary disease

Although inhaled corticosteroids have a well defined role in asthma therapy, their use remains controversial in nonasthmatic, smoking-related chronic obstructive pulmonary disease (COPD). Some studies have shown an effect of inhaled corticosteroids on airway inflammation in COPD, but the clinical relevance of these results is unknown. Data from five long-term, large studies, provide evidence that prolonged treatment with inhaled corticosteroids does not modify the rate of decline of forced expiratory volume in one second (FEV1) in patients with COPD and no reversibility to short-acting beta(2)-agonists. FEV1 was slightly improved over the first six months of treatment and lower reactivity in response to methacholine challenge has been observed. Improvement of respiratory symptoms and health status were also reported. A reduction of exacerbations rate was observed in two studies. No survival benefit was demonstrated. Two recent reports suggest that long term use of inhaled corticosteroids in COPD patients improves quality-adjusted life expectancy and is cost-effective. Combination therapy with inhaled corticosteroids and long-acting beta(2)-agonists have proven benefit in four long term large studies compared to placebo for FEV1, exacerbation rate, symptoms and health status. However, only two studies found that combination therapy was more effective than long-acting beta(2)-agonists alone for symptoms and health status improvement. The long term safety of inhaled corticosteroids is not known in COPD patients but topical adverse effects, and systemic effects such as a decrease of bone density of lumbar spine and femur and cutaneous adverse effects, have been reported after three years of treatment. However, three recent observational studies found a slight increase in the risk of fractures (hip, upper extremities and vertebral) in association with high doses of inhaled corticotherapy.

Acute Exacerbation of COPD

Nurses in acute care settings play a vital role in caring for individuals during an acute exacerbation of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. In addressing this health concern, the Global Initiative for Chronic Obstructive Lung Disease Report summarized the goals for COPD management and recommended treatment supported by current data and research. It is imperative that our clinical nursing practice is based upon research-supported interventions: use of appropriate medications, monitoring acid-base status, administering controlled oxygen therapy, assessing the need for mechanical ventilation, and close monitoring of comorbid illnesses. Health promotion includes patient and family education on early recognition of symptoms, smoking cessation strategies, and participation in pulmonary rehabilitation that can reduce long-term morbidity from this chronic disease.

Invasive pulmonary filamentous fungal infection in a patient receiving inhaled corticosteroid therapy

We report a case of invasive pulmonary filamentous fungal infection in a patient with chronic obstructive pulmonary disease who was treated with a conventional dose of inhaled fluticasone in the absence of other causes of immunosuppression. This case demonstrates the potential risk for opportunistic fungal infections in patients treated with high-potency lipophilic inhaled corticosteroids.

Benefits and risks of inhaled corticosteroids in chronic obstructive pulmonary disease

Inhaled corticosteroids have a proven benefit in the management of asthma, but until recently, their efficacy in non-asthmatic, smoking-related chronic obstructive pulmonary disease (COPD) was not evidence-based. Airway inflammation in COPD differs from inflammation in asthma. Some studies have shown an effect of inhaled corticosteroids on airway inflammation in COPD but the clinical relevance of these results are unknown. Short-term studies evaluating the effect of inhaled corticosteroids in patients with COPD were associated with no or modest improvements in lung function. Data from five, long-term, large studies have provided evidence that prolonged treatment with inhaled corticosteroids does not modify the rate of decline of forced expiratory volume in one second (FEV(1)) in patients with COPD and no reversibility to short-acting beta(2)-adrenoceptor agonists. FEV(1) was slightly improved over the first 6 months of treatment in two studies and lower airway reactivity in response to methacholine challenge has been observed. Improvement of respiratory symptoms and health status was also reported in three studies. A reduction in the rate of exacerbations was observed in two studies. No survival benefit was demonstrated in any study. The advantage of using inhaled, rather than oral, corticosteroids is a reduction in adverse effects for the same therapeutic effect, because inhaled corticosteroids rely more on topical action than systemic activity. The long-term safety of inhaled corticosteroids is not known in patients with COPD. However, topical adverse effects, and systemic effects such as a decrease of bone density of lumbar spine and femur and cutaneous adverse effects, have been reported in patients with COPD after 3 years of treatment with inhaled corticosteroids.

Recent advances in diagnosis and management of chronic bronchitis and emphysema

Chronic obstructive pulmonary disease is a progressive inflammatory disease of the airways and lung parenchyma. Expiratory airflow limitation is the hallmark of chronic obstructive pulmonary disease. It is a significant cause of morbidity and mortality in the United States and worldwide and results in a large consumption of health care resources. Unfortunately, despite efforts to curb this disease, its prevalence is increasing. The diagnosis is usually made when the patient complains of dyspnea on exertion; by this time, irreversible structural damage to the lung has already occurred. Given the nonspecific symptoms of the disease and the inability to effectively treat and reverse the damage, it is essential to diagnose the disease in its early stages and take the necessary preventive measures, thus avoiding disability or death. This review summarizes the latest developments in the diagnosis and management of chronic obstructive pulmonary disease. The first half of the review discusses functional, radiographic, biochemical, and cellular/histopathologic issues in the diagnosis of chronic obstructive pulmonary disease. The second half focuses on the current pharmacologic and nonpharmacologic advances in chronic obstructive pulmonary disease, including the role of respiratory support and surgical treatment. Based on the research on the cellular mechanisms of chronic obstructive pulmonary disease, the review also makes a reference to novel and experimental therapies for chronic obstructive pulmonary disease.