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Lineros R, Fernández-Delgado L, Vega-Rioja A, Chacón P, Doukkali B, Monteseirin J, Ribas-Pérez D. Associated Factors of Pneumonia in Individuals with Chronic Obstructive Pulmonary Disease (COPD) Apart from the Use of Inhaled Corticosteroids. Biomedicines 2023; 11:biomedicines11051243. [PMID: 37238914 DOI: 10.3390/biomedicines11051243] [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: 03/07/2023] [Revised: 04/09/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
Inhaled corticosteroids (ICSs) are widely used in chronic obstructive pulmonary disease (COPD) and in combination with long-acting β2 agonists (LABAs) to reduce exacerbations and improve patient lung function and quality of life. However, ICSs have been associated with an increased risk of pneumonia in individuals with COPD, although the magnitude of this risk remains unclear. Therefore, it is difficult to make informed clinical decisions that balance the benefits and adverse effects of ICSs in people with COPD. There may be other causes of pneumonia in patients with COPD, and these causes are not always considered in studies on the risks of using ICSs in COPD. We consider it very useful to clarify these aspects in assessing the influence of ICSs on the incidence of pneumonia and their role in the treatment of COPD. This issue has important implications for current practice and the evaluation and management of COPD, since COPD patients may benefit from specific ICS-based treatment strategies. Many of the potential causes of pneumonia in patients with COPD can act synergistically, so they can be included in more than one section.
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Affiliation(s)
- Rosario Lineros
- Unidad Salud Mental, Hospital Vázquez Díaz, 21080 Huelva, Spain
| | | | - Antonio Vega-Rioja
- UGC de Alergología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | - Pedro Chacón
- UGC de Alergología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | - Bouchra Doukkali
- UGC de Alergología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | | | - David Ribas-Pérez
- Department of Stomatology, Faculty of Dentistry, University of Seville, 41004 Seville, Spain
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Wang N, Liu BW, Ma CM, Yan Y, Su QW, Yin FZ. Influence of overweight and obesity on the mortality of hospitalized patients with community-acquired pneumonia. World J Clin Cases 2022; 10:104-116. [PMID: 35071510 PMCID: PMC8727241 DOI: 10.12998/wjcc.v10.i1.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/28/2021] [Accepted: 11/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obesity is associated with a better prognosis in patients with community-acquired pneumonia (the so-called obesity survival paradox), but conflicting results have been found.
AIM To investigate the relationship between all-cause mortality and body mass index in patients with community-acquired pneumonia.
METHODS This retrospective study included patients with community-acquired pneumonia hospitalized in the First Hospital of Qinhuangdao from June 2013 to November 2018. The patients were grouped as underweight (< 18.5 kg/m2), normal weight (18.5-23.9 kg/m2), and overweight/obesity (≥ 24 kg/m2). The primary outcome was all-cause hospital mortality.
RESULTS Among 2327 patients, 297 (12.8%) were underweight, 1013 (43.5%) normal weight, and 1017 (43.7%) overweight/obesity. The all-cause hospital mortality was 4.6% (106/2327). Mortality was lowest in the overweight/obesity group and highest in the underweight group (2.8%, vs 5.0%, vs 9.1%, P < 0.001). All-cause mortality of overweight/obesity patients was lower than normal-weight patients [odds ratio (OR) = 0.535, 95% confidence interval (CI) = 0.334-0.855, P = 0.009], while the all-cause mortality of underweight patients was higher than that of normal-weight patients (OR = 1.886, 95%CI: 1.161-3.066, P = 0.010). Multivariable analysis showed that abnormal neutrophil counts (OR = 2.38, 95%CI: 1.55-3.65, P < 0.001), abnormal albumin levels (OR = 0.20, 95%CI: 0.06-0.72, P = 0.014), high-risk Confusion-Urea-Respiration-Blood pressure-65 score (OR = 2.89, 95%CI: 1.48-5.64, P = 0.002), and intensive care unit admission (OR = 3.11, 95%CI: 1.77-5.49, P < 0.001) were independently associated with mortality.
CONCLUSION All-cause mortality of normal-weight patients was higher than overweight/ obesity patients, lower than that of underweight patients. Neutrophil counts, albumin levels, Confusion-Urea-Respiration-Blood pressure-65 score, and intensive care unit admission were independently associated with mortality in patients with community-acquired pneumonia.
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Affiliation(s)
- Ning Wang
- Department of Endocrinology, Hebei Medical University, Shijiazhuang 050017, Hebei Province, China
| | - Bo-Wei Liu
- Department of Endocrinology, First Hospital of Qinhuangdao, Qinhuangdao 066001, Hebei Province, China
| | - Chun-Ming Ma
- Department of Endocrinology, First Hospital of Qinhuangdao, Qinhuangdao 066001, Hebei Province, China
| | - Ying Yan
- Department of Endocrinology, Chengde Medical University, Chengde 067000, Hebei Province, China
| | - Quan-Wei Su
- Department of Endocrinology, Chengde Medical University, Chengde 067000, Hebei Province, China
| | - Fu-Zai Yin
- Department of Endocrinology, First Hospital of Qinhuangdao, Qinhuangdao 066001, Hebei Province, China
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Vivarelli F, Canistro D, Cirillo S, Elias RJ, Granata S, Mussoni M, Burattini S, Falcieri E, Turrini E, Fimognari C, Buschini A, Lazzaretti M, Beghi S, Girotti S, Sangiorgi S, Bolelli L, Ghini S, Ferri EN, Fagiolino I, Franchi P, Lucarini M, Mercatante D, Rodriguez-Estrada MT, Lorenzini A, Marchionni S, Gabriele M, Longo V, Paolini M. Unburned Tobacco Cigarette Smoke Alters Rat Ultrastructural Lung Airways and DNA. Nicotine Tob Res 2021; 23:2127-2134. [PMID: 34036368 DOI: 10.1093/ntr/ntab108] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Recently, the Food and Drug Administration authorized the marketing of IQOS Tobacco Heating System as a Modified Risk Tobacco Product based on an electronic heat-not-burn technology that purports to reduce the risk. METHODS Sprague-Dawley rats were exposed in a whole-body mode to IQOS aerosol for 4 weeks. We performed the chemical characterization of IQOS mainstream and we studied the ultrastructural changes in trachea and lung parenchyma of rats exposed to IQOS stick mainstream and tissue pro-inflammatory markers. We investigated the reactive oxygen species amount along with the markers of tissue and DNA oxidative damage. Moreover, we tested the putative genotoxicity of IQOS mainstream through Ames and alkaline Comet mutagenicity assays. RESULTS Here, we identified irritating and carcinogenic compounds including aldehydes and polycyclic aromatic hydrocarbons in the IQOS mainstream as sign of incomplete combustion and degradation of tobacco, that lead to severe remodelling of smaller and largest rat airways. We demonstrated that IQOS mainstream induces lung enzymes that activate carcinogens, increases tissue reactive radical concentration; promotes oxidative DNA breaks and gene level DNA damage; and stimulates mitogen activated protein kinase pathway which is involved in the conventional tobacco smoke-induced cancer progression. CONCLUSIONS Collectively, our findings reveal that IQOS causes grave lung damage and promotes factors that increase cancer risk. IMPLICATIONS IQOS has been proposed as a safer alternative to conventional cigarettes, due to depressed concentration of various harmful constituents typical of traditional tobacco smoke. However, its lower health risks to consumers have yet to be determined. Our findings confirm that IQOS mainstream contains pyrolysis and thermogenic degradation by-products, the same harmful constituents of traditional cigarette smoke, and, for the first time, we show that it causes grave lung damage and promotes factors that increase cancer risk in the animal model.
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Affiliation(s)
- Fabio Vivarelli
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Donatella Canistro
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Silvia Cirillo
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Ryan J Elias
- Department of Food Science, College of Agricultural Sciences, Pennsylvania State University, University Park, PA, USA
| | - Silvia Granata
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Matilde Mussoni
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Sabrina Burattini
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Elisabetta Falcieri
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Eleonora Turrini
- Department for Life Quality Studies, Alma Mater Studiorum-University of Bologna, Rimini, Italy
| | - Carmela Fimognari
- Department for Life Quality Studies, Alma Mater Studiorum-University of Bologna, Rimini, Italy
| | - Annamaria Buschini
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Mirca Lazzaretti
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Sofia Beghi
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Stefano Girotti
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Stefano Sangiorgi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Luca Bolelli
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Severino Ghini
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Elida Nora Ferri
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | | | - Paola Franchi
- Department of Chemistry "G. Ciamician," Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Marco Lucarini
- Department of Chemistry "G. Ciamician," Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Dario Mercatante
- Department of Agricultural and Food Sciences, Alma Mater Studiorum-University di Bologna, Bologna, Italy
| | - Maria Teresa Rodriguez-Estrada
- Department of Agricultural and Food Sciences, Alma Mater Studiorum-University di Bologna, Bologna, Italy
- Inter-Departmental Centre for Agri-Food Industrial Research, Alma Mater Studiorum-University of Bologna, Cesena, Italy
| | - Antonello Lorenzini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Silvia Marchionni
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna,Italy
| | - Morena Gabriele
- Department of Agricultural Biology and Biotechnology, CNR, Pisa, Italy
| | - Vincenzo Longo
- Department of Agricultural Biology and Biotechnology, CNR, Pisa, Italy
| | - Moreno Paolini
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna,Italy
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Rodrigues SDO, da Cunha CMC, Soares GMV, Silva PL, Silva AR, Gonçalves-de-Albuquerque CF. Mechanisms, Pathophysiology and Currently Proposed Treatments of Chronic Obstructive Pulmonary Disease. Pharmaceuticals (Basel) 2021; 14:979. [PMID: 34681202 PMCID: PMC8539950 DOI: 10.3390/ph14100979] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/13/2021] [Accepted: 08/28/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading global causes of morbidity and mortality. A hallmark of COPD is progressive airflow obstruction primarily caused by cigarette smoke (CS). CS exposure causes an imbalance favoring pro- over antioxidants (oxidative stress), leading to transcription factor activation and increased expression of inflammatory mediators and proteases. Different cell types, including macrophages, epithelial cells, neutrophils, and T lymphocytes, contribute to COPD pathophysiology. Alteration in cell functions results in the generation of an oxidative and inflammatory microenvironment, which contributes to disease progression. Current treatments include inhaled corticosteroids and bronchodilator therapy. However, these therapies do not effectively halt disease progression. Due to the complexity of its pathophysiology, and the risk of exacerbating symptoms with existing therapies, other specific and effective treatment options are required. Therapies directly or indirectly targeting the oxidative imbalance may be promising alternatives. This review briefly discusses COPD pathophysiology, and provides an update on the development and clinical testing of novel COPD treatments.
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Affiliation(s)
- Sarah de Oliveira Rodrigues
- Laboratório de Imunofarmacologia, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil;
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
- Programa de Pós-Graduação em Ciências e Biotecnologia, Universidade Federal Fluminense, Rio de Janeiro 24020-140, Brazil
| | - Carolina Medina Coeli da Cunha
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
| | - Giovanna Martins Valladão Soares
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
| | - Pedro Leme Silva
- Laboratório de Investigação Pulmonar, Carlos Chagas Filho, Instituto de Biofísica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil;
| | - Adriana Ribeiro Silva
- Laboratório de Imunofarmacologia, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil;
- Programa de Pós-Graduação em Ciências e Biotecnologia, Universidade Federal Fluminense, Rio de Janeiro 24020-140, Brazil
- Programa de Pós-Graduação em Biologia Celular e Molecular, Instituto Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil
| | - Cassiano Felippe Gonçalves-de-Albuquerque
- Laboratório de Imunofarmacologia, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro 21040-900, Brazil;
- Laboratório de Imunofarmacologia, Departamento de Bioquímica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20211-010, Brazil; (C.M.C.d.C.); (G.M.V.S.)
- Programa de Pós-Graduação em Ciências e Biotecnologia, Universidade Federal Fluminense, Rio de Janeiro 24020-140, Brazil
- Programa de Pós-Graduação em Biologia Molecular e Celular, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20210-010, Brazil
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Beech AS, Lea S, Kolsum U, Wang Z, Miller BE, Donaldson GC, Wedzicha JA, Brightling CE, Singh D. Bacteria and sputum inflammatory cell counts; a COPD cohort analysis. Respir Res 2020; 21:289. [PMID: 33131502 PMCID: PMC7603729 DOI: 10.1186/s12931-020-01552-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/20/2020] [Indexed: 01/08/2023] Open
Abstract
Background There is evidence that bacterial colonisation in chronic obstructive pulmonary disease (COPD) is associated with increased neutrophilic airway inflammation. This study tested the hypothesis that different bacterial phyla and species cause different inflammatory profiles in COPD patients. Methods Sputum was analysed by quantitative polymerase chain reaction (qPCR) to quantify bacterial load and 16S rRNA gene sequencing to identify taxonomic composition. Sputum differential cell counts (DCC) and blood DCC were obtained at baseline and 6 months. Patients were categorised into five groups based on bacterial load defined by genome copies/ml of ≥ 1 × 104, no colonisation and colonisation by Haemophilus influenzae (H. influenzae), Moraxella catarrhalis (M. catarrhalis), Streptococcus pneumoniae (S. pneumoniae), or > 1 potentially pathogenic microorganism (PPM). Results We observed an increase in sputum neutrophil (%), blood neutrophil (%) and neutrophil–lymphocyte ratio (NLR) in patients colonised with H. influenzae (82.6, 67.1, and 3.29 respectively) compared to those without PPM colonisation at baseline (69.5, 63.51 and 2.56 respectively) (p < 0.05 for all analyses), with similar findings at 6 months. The bacterial load of H. influenzae and Haemophilus determined by qPCR and 16s rRNA gene sequencing respectively, and sputum neutrophil % were positively correlated between baseline and 6 months visits (p < 0.0001, 0.0150 and 0.0002 with r = 0.53, 0.33 and 0.44 respectively). Conclusions These results demonstrate a subgroup of COPD patients with persistent H. influenzae colonisation that is associated with increased airway and systemic neutrophilic airway inflammation, and less eosinophilic airway inflammation.
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Affiliation(s)
- Augusta S Beech
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK. .,Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9QZ, UK.
| | - Simon Lea
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Umme Kolsum
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Zhang Wang
- Institute of Ecological Sciences, School of Life Sciences, South China Normal University, Guangzhou, China
| | - Bruce E Miller
- Medical Innovation, Value Evidence and Outcomes, GSK R&D, Collegeville, PA, USA
| | - Gavin C Donaldson
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9QZ, UK
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Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome and may comprise several different phenotypes that are driven by different molecular mechanisms (endotypes). Several different clinical, genetic, and inflammatory phenotypes of COPD have been recognized and this may lead to more precise effective therapies. AREAS COVERED The different clinical phenotypes, including smoking versus nonsmoking COPD, small airway disease versus emphysema, non-exacerbators versus frequent exacerbators are discussed. Rare genetic endotypes (alpha1-antitrypsin deficiency, telomerase polymorphisms), and inflammatory phenotypes (eosinophilic versus neutrophilic) are also recognized in stable and exacerbating patients and have implications for the choice of therapy. EXPERT OPINION Clinical phenotypes have so far not proved to be very useful in selecting more personalized therapy for COPD. Even with genetic endotypes, this has not led to improved therapy. More promising is the recognition that COPD patients who have increased sputum or blood eosinophils tend to have more frequent exacerbations and inhaled corticosteroids are more effective in preventing exacerbation. Increased blood eosinophils have proved to be a useful biomarker now used to target ICS more effectively. Furthermore, COPD patients with low eosinophils are more likely to get pneumonia with ICS and to have lower airway bacterial colonization.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College London , London, UK
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Hartley BF, Barnes NC, Lettis S, Compton CH, Papi A, Jones P. Risk factors for exacerbations and pneumonia in patients with chronic obstructive pulmonary disease: a pooled analysis. Respir Res 2020; 21:5. [PMID: 31907054 PMCID: PMC6945447 DOI: 10.1186/s12931-019-1262-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/13/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) are at risk of exacerbations and pneumonia; how the risk factors interact is unclear. METHODS This post-hoc, pooled analysis included studies of COPD patients treated with inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) combinations and comparator arms of ICS, LABA, and/or placebo. Backward elimination via Cox's proportional hazards regression modelling evaluated which combination of risk factors best predicts time to first (a) pneumonia, and (b) moderate/severe COPD exacerbation. RESULTS Five studies contributed: NCT01009463, NCT01017952, NCT00144911, NCT00115492, and NCT00268216. Low body mass index (BMI), exacerbation history, worsening lung function (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage), and ICS treatment were identified as factors increasing pneumonia risk. BMI was the only pneumonia risk factor influenced by ICS treatment, with ICS further increasing risk for those with BMI <25 kg/m2. The modelled probability of pneumonia varied between 3 and 12% during the first year. Higher exacerbation risk was associated with a history of exacerbations, poorer lung function (GOLD stage), female sex and absence of ICS treatment. The influence of the other exacerbation risk factors was not modified by ICS treatment. Modelled probabilities of an exacerbation varied between 31 and 82% during the first year. CONCLUSIONS The probability of an exacerbation was considerably higher than for pneumonia. ICS reduced exacerbations but did not influence the effect of risks associated with prior exacerbation history, GOLD stage, or female sex. The only identified risk factor for ICS-induced pneumonia was BMI <25 kg/m2. Analyses of this type may help the development of COPD risk equations.
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Affiliation(s)
| | - Neil C Barnes
- GlaxoSmithKline plc, Brentford, UK
- William Harvey Institute, Bart's and the London School of Medicine and Dentistry, London, UK
| | | | | | | | - Paul Jones
- GlaxoSmithKline plc, Brentford, UK
- Institute of Infection and Immunity, St George's, University of London, London, UK
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