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

Association between inhaled corticosteroid use and risk of hyperglycemia in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

Objectives

Chronic obstructive pulmonary disease (COPD) patients have a higher risk of developing diabetes, and studies suggest that inhaled corticosteroids (ICSs) use may be associated with a higher risk of diabetes, particularly at higher doses. This study aims to investigate the effects of ICS use on the risk of diabetes and blood glucose levels in COPD patients.

Materials and Methods

A systematic search was carried out on the PubMed, EBSCOhost, and ProQuest databases using the terms "Inhaled Corticosteroids," "Diabetes," and "Chronic Obstructive Pulmonary Disease" for the period between 2013 and 2023. The systematic review adhered to the PRISMA 2020 guideline. A meta-analysis was conducted using a random-effects model using the RevMan 5 software.

Results

A total of 14 studies were included in the final analysis, with 10 randomized controlled trials (RCTs) and 4 observational studies. Two observational studies investigated the relationship between ICS dose and diabetes risk. A meta-analysis of the RCTs studies showed a nonstatistically significant tendency toward increased blood glucose (odds ratio [OR] 1.07 and 95% confidence interval [CI] 0.88-1.30) after a 52-week follow-up. Whereas the observational studies showed a tendency toward an increased risk of diabetes (OR 1.40 and 95% CI 0.96-2.03). Furthermore, a subgroup meta-analysis of high-dose ICS (>900 μg/day) showed a significant increase in the risk of diabetes (OR 1.20 and 95% CI 1.09-1.32).

Conclusion

Short-term use of ICS does not have a significant effect on blood glucose. However, long-term use, especially at higher doses, can increase the risk of developing diabetes.

Impact of inhaled and intranasal corticosteroids on glucose metabolism and diabetes mellitus: A mini review

Inhaled corticosteroids (ICS) and intranasal corticosteroids (INS) are the mainstays of treatment for chronic respiratory diseases like asthma, chronic obstructive pulmonary disease, and allergic rhinosinusitis. In addition, these localized forms of steroid therapy are generally considered to have fewer systemic side effects compared to long-term oral corticosteroids. However, concern and controversy remain over the impact of ICS and INS on the incidence and control of diabetes mellitus (DM). Given the widespread use of ICS and INS, even small individual effects on DM could lead to large consequences for the global popu-lation. Multiple large observational studies suggest that high dose ICS is associated with increased incident DM and worsened DM control, though the contribution of other risk factors is less certain. In addition, only two studies were done to investigate the association of INS and DM, with both studies demon-strating a short-term association of INS use with hyperglycemia. While more research evaluating the risk of ICS/INS for DM-related adverse events is needed, high doses of ICS/INS should be avoided when possible. The following strategies for ICS/INS dose minimization can be considered: Use of non-pharmacological measures (trigger avoidance, smoking cessation, vaccination to avoid infection), control of comorbid conditions, use of non-ICS-containing medications, inter-mittent rather than regular ICS dosing, and appropriate de-escalation of high ICS doses.

Inhaled corticosteroids and adverse outcomes among chronic obstructive pulmonary disease patients with community-acquired pneumonia: a population-based cohort study

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.

All-Cause, Cardiovascular and Respiratory Mortality in People with Type 2 Diabetes and Chronic Obstructive Pulmonary Disease (COPD) in England: A Cohort Study Using the Clinical Practice Research Datalink (CPRD)

Background

Type 2 diabetes (T2D) and chronic obstructive pulmonary disease (COPD) are common non-communicable diseases. Both have an inflammatory nature and similar risk factors, and there is overlap and interaction between them. To date, there is a lack of research on outcomes in people that have both conditions. The aim of this study was to investigate whether the presence of COPD in people with T2D was associated with an increased risk of all-cause, respiratory-cause and cardiovascular-cause mortality.

Methods

A three-year cohort study (2017-19) was done using the Clinical Practice Research Datalink Aurum database. The study population was 121,563 people with T2D aged ≥40. The exposure was COPD status at baseline. Incident rates for all-cause, respiratory-cause and cardiovascular-cause mortality were calculated. Poisson models for each outcome were fitted to estimate rate ratios for COPD status adjusted for age, sex, Index of Multiple Deprivation, smoking status, body mass index, prior asthma and cardiovascular disease.

Results

COPD was present in 12.1% people with T2D. People with COPD had a higher all-cause mortality rate (448.7 persons per 1000 person years) compared with people without COPD (296.6 persons per 1000 person years). People with COPD also had substantially higher respiratory mortality incidence rates and moderately raised cardiovascular mortality rates. Fully adjusted Poisson models showed that people with COPD had a 1.23 (95% CI 1.21, 1.24) times higher rate of all-cause mortality as compared with those without COPD and a 3.03 (95% CI 2.89, 3.18) times higher rate of respiratory-cause mortality. There was no evidence of an association with cardiovascular mortality after adjusting for existing cardiovascular disease.

Conclusion

Co-morbid COPD in people with T2D was associated with increased mortality overall and particularly from respiratory causes. People with both COPD and T2D are a high-risk group who would benefit from particularly intensive management of both conditions.

Study protocol: pneumonia and inhaled corticosteroid treatment patterns in chronic obstructive pulmonary disease - a cohort study using sequence analysis (PICCS)

INTRODUCTION

Treatment with inhaled corticosteroids (ICS) is a widely used treatment in chronic obstructive pulmonary disease. The main effects include a reduction in the number of exacerbations and, for some patients, an increase in expected mortality. Unfortunately, the treatment is also linked to an increased risk of pneumonia, and very little is known about which patients experience this increased risk. There is a need for identification of patient characteristics associated with increased risk of pneumonia and treatment with ICS.

METHODS AND ANALYSIS

This is a register-based cohort study that uses the nationwide Danish registers. Data from several registers in the years 2008-2018 will be merged on an individual level using the personal identification numbers that are unique to every citizen in Denmark. Clusters based on pneumonia incidence and ICS treatment patterns will be explored with a sequence analysis in a 3-year follow-up period.

ETHICS AND DISSEMINATION

This is a register-based study and research ethics approval is not required according to Danish Law and National Ethics Committee Guidelines. The results will be submitted to peer-reviewed journals and reported at appropriate national and international meetings.

The clinical efficacy of type 2 monoclonal antibodies in eosinophil-associated chronic airway diseases: a meta-analysis

Background

Anti-type 2 inflammation therapy has been proposed as a treatment strategy for eosinophil-associated chronic airway disorders that could reduce exacerbations and improve lung function. We performed a meta-analysis of randomized controlled trials to assess the effectiveness of type 2 monoclonal antibodies (anti-T2s) for eosinophil-associated chronic airway disorders.

Methods

PubMed, Embase, Web of Science, and Cochrane Library were searched from their inception to 21 August 2022. Randomized clinical trials evaluating the effectiveness of anti-T2s versus placebo in the treatment of chronic airway diseases were selected. The outcomes were exacerbation rate and change in pre-bronchodilator forced expiratory volume in 1 s (FEV1) from baseline. The Cochrane Risk of Bias Assessment Tool 1.0 was used to evaluate the risk of bias, and the random-effects or fixed-effect model were used to pool the data.

Results

Thirty-eight articles concerning forty-one randomized clinical trials with 17,115 patients were included. Compared with placebo, anti-T2s therapy yielded a significant reduction in exacerbation rate in COPD and asthma (Rate Ratio (RR)=0.89, 95%CI, 0.83-0.95, I2 = 29.4%; RR= 0.59, 95%CI, 0.52-0.68, I2 = 83.9%, respectively) and improvement in FEV1 in asthma (Standard Mean Difference (SMD)=0.09, 95%CI, 0.08-0.11, I2 = 42.6%). Anti-T2s therapy had no effect on FEV1 improvement in COPD (SMD=0.05, 95%CI, -0.01-0.10, I2 = 69.8%).

Conclusion

Despite inconsistent findings across trials, anti-T2s had a positive overall impact on patients' exacerbation rate in asthma and COPD and FEV1 in asthma. Anti-T2s may be effective in treating chronic airway illnesses related to eosinophils.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022362280.

Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today?

INTRODUCTION

As of today, there is still a need to determine which COPD patients may benefit from ICS therapy, whether ICSs are useful in COPD patients without chronic bronchitis, and whether long-acting bronchodilators can reduce the risk of exacerbations in frequent exacerbators even if ICSs are not used, and whether combination therapy including ICSs is helpful in infrequent exacerbators to optimise the use of ICSs in COPD. Nevertheless, in recent years, a fair amount of evidence has been produced that, at least in part, can help define the role of ICSs in COPD better.

AREAS COVERED

Herein, the authors provide an overview of current use of ICS in COPD and discuss their value to the current treatment armamentarium. The article includes discussion of which patients will benefit best from the use of ICSs, their potential uses and adverse effects.

EXPERT OPINION

There is growing agreement on why, in whom, and when ICS therapy can be used in COPD, although the consensus is still lacking because of the heterogeneity of COPD. The use of blood eosinophil counts (BECs) is only helpful in T2 inflammation, while there is a lack of biomarkers indicating the presence of T1 and T17 immunity, which is poorly responsive to ICS. Identifying ICS-sensitive endotypes using specific biomarkers that have yet to be identified and validated is likely to demonstrate that ICSs can influence the natural course of COPD in at least a subset of patients.

Asthma in Youth and Early-onset Type 2 Diabetes: A Nationwide Study of 1.72 Million Israeli Adolescents

BACKGROUND

The prevalence of both asthma and early-onset diabetes is on the rise; however, the association between them remains unclear. We examined a possible association of asthma at adolescence with type 2 diabetes in young adulthood.

METHODS

This is a nationwide, population-based study of 1 718 541 Israeli adolescents (57% males; mean age 17.3 years; range 16-19 years), examined before compulsory military service between 1992 and 2016, with data linked to the Israeli National Diabetes Registry. Asthma diagnosis and severity were determined by a board-certified pulmonologist and based on spirometry tests.

RESULTS

Type 2 diabetes developed in 58/9090 (0.64%), 507/97 059 (0.52%), 114/23 332 (0.49%), and 7095/1 589 060 (0.44%) persons with moderate-to-severe, mild, inactive, and no history of asthma, respectively, during a mean follow-up >13 years. The respective odds ratios (ORs) were 1.33 (95% CI, 1.02-1.74), 1.17 (1.06-1.28), and 1.09 (0.9-1.31), considering those without asthma history as the reference, in a model adjusted for birth year, sex, body mass index, and other sociodemographic variables. The association persisted when the analysis accounted for coexisting morbidities, and when persons without asthma, individually matched by age, sex, birth year, and body mass index were the reference. Both mild and moderate-to-severe asthma were associated with type 2 diabetes before age 35 years: ORs 1.18 (1.05-1.34) and 1.44 (1.05-2.00), respectively. The strength of the association was accentuated over time. The effect was unchanged when adjusted for oral and inhaled glucocorticoid use.

CONCLUSION

Adolescents with active asthma have higher risk to develop type 2 diabetes. This seems related to disease severity, independent of adolescent obesity status, apparent before age 35 years, and more pronounced in recent years.

Biomarkers in Chronic Obstructive Pulmonary Disease: Emerging Roles of Eosinophils and Procalcitonin

Antibiotics can improve the prognosis in patients with exacerbation of chronic obstructive pulmonary disease. However, the overuse of antibiotics can carry serious adverse effects for patients (gastrointestinal infections) and for society (bacterial resistance). Likewise, systemic corticosteroids may also help these patients, but also carries severe adverse effects like osteoporosis, muscle loss, and diabetes, in many patients. Whenever safe methods exist to reduce these two treatment modalities, they should be implemented. The blood biomarkers procalcitonin and the fraction of leukocytes known as eosinophil granulocytes have been proven in randomized controlled trials (RCTs), to effectively, significantly, and substantially assist in reducing the use of these two potent, yet toxic medication types. In this review, the background and main clinical results are discussed, explaining the rationale for biomarker-guided clinical decisions. Also, the main expected effects, their sizes, and importantly the limitations to such a strategy are described. Clinical evidence is prioritized with main weight on RCTs and meta-analyses of these and regarding outcomes, and focus is set on the safety of such a biomarker-guided strategy, as well as the effects on medicine reduction. In an epoch of increasing demands to physicians from patients and politicians to cure and reduce symptoms, the Hippocratic phrase of "primum non nocere" or "first, do no harm" seems more than ever of contemporary importance.

Systemic Corticosteroids and the Risk of Venous Thromboembolism in Patients with Severe COPD: A Nationwide Study of 30,473 Outpatients

Due to frequent exacerbations, many patients with chronic obstructive pulmonary disease (COPD) are exposed to oral corticosteroids (OCS), which may be thrombogenic. We evaluated the risk of hospitalisation with venous thromboembolism (VTE) and death in patients with acute exacerbation of COPD (AECOPD) treated with long and short OCS regimens. In this nationwide cohort study of 30,473 COPD outpatients treated for AECOPD, we compared the risk of VTE hospitalisation and all-cause mortality within 6 months in OCS dose of >250 mg vs. ≤250 mg. A multivariable Cox proportional hazard regression was used to estimate the risk. The incidence of VTE hospitalisations was 0.23%. A long OCS treatment course was associated with an increased risk of VTE compared to a short course (hazard ratio (HR) 1.69, [95% confidence interval (CI) 1.05 to 2.72], p < 0.031). A higher risk of all-cause mortality was seen in the group of COPD patients treated with a long OCS course (HR 1.71, [95% CI 1.63 to 1.79], p < 0.0001). The risk of reported VTE hospitalisation was higher among AECOPD patients treated with long courses of OCS, but the absolute risk was low, suggesting under-reporting of the condition.

Association between ICS use and risk of hyperglycemia in COPD patients: systematic review and meta-analysis

BACKGROUND

The effect of inhaled corticosteroids (ICS) on risk of hyperglycemia in patients with chronic obstructive pulmonary disease (COPD) remains ambiguous. The aim of this study is to evaluate the association between ICS use and the incidence of hyperglycemia related adverse effects in COPD patients.

METHODS

Medline/PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched from inception to 25 May 2020. Randomized controlled trials (RCTs) of ICS versus control (non-ICS) treatment for COPD patients reporting on risk of hyperglycemia were included. The Mantel-Haenszel method with fixed-effects modeling was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

Seventeen RCTs with 43,430 subjects were included in the meta-analysis. Pooled results suggested that there was no statistically significant difference in the risk of hyperglycemia between the ICS group and the control group (RR 1.02, 95% CI 0.90-1.16, P = 0.76). In addition, no significant difference was noted in the effect on glucose level (RR 1.20, 95% CI 0.79-1.82, P = 0.40), risk of diabetes progression (RR 0.84, 95% CI 0.20-3.51, P = 0.81) and new onset diabetes mellitus (RR 1.0, 95% CI 0.88-1.15, P = 0.95) between the ICS group and the control group. These findings also were consistent across all subgroup analyses.

CONCLUSIONS

Use of ICS does not have an effect on the blood glucose and is not associated with the risk of new onset diabetes mellitus and diabetes progression in patients with COPD. Further RCTs exploring the association between ICS use and risk of hyperglycemia in COPD patients are still needed to verify our results of this analysis.

Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD

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.

Corticosteroid Resistance in Smokers-A Substudy Analysis of the CORTICO-COP Randomised Controlled Trial

The CORTICO-COP trial showed that eosinophil-guided corticosteroid-sparing treatment for acute exacerbation of chronic obstructive pulmonary disease was non-inferior to standard of care and decreased the accumulated dose of systemic corticosteroids that patients were exposed to by approximately 60%. Smoking status has been shown to affect corticosteroid responsiveness. This post hoc analysis investigated whether eosinophil-guided treatment is non-inferior to conventional treatment in current smokers. The main analysis of current smokers showed no significant difference in the primary endpoint, days alive, and out of hospital within 14 days between the control group (mean, 9.8 days; 95% confidence interval (CI), 8.7-10.8) and the eosinophil-guided group (mean, 8.7 days; 95% CI, 7.5-9.9; p = 0.34). Secondary analyses of the number of exacerbations or deaths, the number of intensive care unit admissions or deaths, lung function improvement, and change in health-related quality of life also showed no significant differences between the two groups. The results of a sensitivity analysis of ex-smokers are consistent with the main analysis. Our results suggest that eosinophil-guided treatment is non-inferior to standard of care in current smokers and ex-smokers. Because data on the impact of smoking status on eosinophil-guided treatments are sparse, more randomised trials are needed to confirm our results.

Does inhaled corticosteroid use affect the risk of COVID-19-related death?

ICS does not seem to protect against COVID-19-related mortality, but more data is needed to determine whether it is harmful. Due to its known and important benefits ICS should be prescribed as usual for both asthma and COPD. https://bit.ly/3pWVimX.

Using Blood Eosinophil Count as a Biomarker to Guide Corticosteroid Treatment for Chronic Obstructive Pulmonary Disease

Treating patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (COPD) usually involves administering systemic corticosteroids. The many unwanted side effects associated with this treatment have led to increased interest in minimising the accumulated corticosteroid dose necessary to treat exacerbations. Studies have shown that short-term treatment with corticosteroids is preferred, and recent trials have shown that biomarkers can be used to further reduce exposure to corticosteroids. Interestingly, high eosinophil counts in patients with acute exacerbations of COPD are indicative of an eosinophilic phenotype with a distinct response to treatment with corticosteroids. In addition, post-hoc analysis of randomised control trials have shown that higher blood eosinophil counts at the start of the study predict a greater response to inhaled corticosteroids in stable COPD. In this review, we examine the studies on this topic, describe how blood eosinophil cell count may be used as a biomarker to guide treatment with corticosteroids, and identify some relevant challenges.

Inhaled corticosteroids and the risk of type 2 diabetes among Swedish COPD patients

This study reports the association of ICS use and the risk of type 2 diabetes mellitus (T2DM) in Swedish patients with COPD using data from real-world, primary care settings. A total of 7078 patients with COPD were included in this analysis and the 5-year cumulative incidence rate per 100,000 person years was 1506.9. The yearly incidence rate per 100,000 person years ranged from 850 to 1919. Use of ICS especially at a high dose in patients with COPD was related to an increased risk of T2DM.