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Letters to the editor
Inhaled corticosteroids and mortality in COPD
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  1. D D Sin
  1. for the ISEEC Steering Committee
  1. Correspondence to:
    Associate Professor D D Sin
    James Hogg iCAPTURE Center for Cardiovascular and Pulmonary Research, St Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; dsin{at}mrl.ubc.ca

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    In his letter published in the August edition of Thorax, Dr Stirling1 raises many issues regarding the role of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD). As pointed out by Dr Stirling, there are compelling data to indicate that inhaled corticosteroids reduce clinically relevant exacerbations by nearly a third and improve health status and quality of life for patients with COPD.2,3 They also reduce emergency visits and hospital admissions.4 Our pooled analysis extends these findings by demonstrating a salutary effect on mortality.5 The precise mechanism(s) by which these effects occur are uncertain.

    COPD is an inflammatory disorder which is characterised by both local lung and systemic inflammation6,7 and the intensity of the inflammatory process relates to COPD progression.8 Inhaled corticosteroids appear to attenuate lung and systemic inflammation.9–,11 However, inhaled corticosteroids have pleotropic effects and some of these effects—such as restoring β2 adrenoceptor sensitivity and reducing oxidant load in the airways—may be of relevance in COPD.12 As such, it would be premature and presumptuous to attribute the clinical benefits exclusively to their anti-inflammatory properties. While oral corticosteroids are more powerful anti-inflammatory agents than are inhaled corticosteroids, they are also fraught with many side effects.13 Accordingly, they cannot be recommended for long term use in most patients.

    We agree with Dr Stirling that there are other effective interventions in COPD—including smoking cessation, pulmonary rehabilitation, and co-morbidity management—that deserve attention.14 Inhaled corticosteroids should not replace any of these effective interventions; rather, they should be regarded as complementary therapies in the management of COPD.

    References

    1. ↵
      Stirling R. Inhaled corticosteroids and mortality in COPD: are we there yet? Thorax2006;61:735.
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    2. ↵
      Alsaeedi A, Sin DD, McAlister FA. The effects of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review of randomized placebo-controlled trials. Am J Med2002;113:59–65.
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      Burge PS, Calverley PM, Jones PW, et al. Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial. BMJ2000;320:1297–303.
      OpenUrlAbstract/FREE Full Text
    4. ↵
      Lung Health Study Research Group. Effect of inhaled triamcinolone on the decline in pulmonary function in chronic obstructive pulmonary disease. N Engl J Med2000;343:1902–9.
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    5. ↵
      Sin DD, Wu L, Anderson JA, et al. Inhaled corticosteroids and mortality in chronic obstructive pulmonary disease. Thorax2005;60:992–7.
      OpenUrlAbstract/FREE Full Text
    6. ↵
      Hogg JC, Chu F, Utokaparch S, et al. The nature of small-airway obstruction in chronic obstructive pulmonary disease. N Engl J Med2004;350:2645–53.
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      Sin DD, Man SF. Why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? The potential role of systemic inflammation in chronic obstructive pulmonary disease. Circulation2003;107:1514–9.
      OpenUrlAbstract/FREE Full Text
    8. ↵
      Donaldson GC, Seemungal TA, Patel IS, et al. Airway and systemic inflammation and decline in lung function in patients with COPD. Chest2005;128:1995–2004.
      OpenUrlCrossRefPubMedWeb of Science
    9. ↵
      Gan WQ, Man SF, Sin DD. Effects of inhaled corticosteroids on sputum cell counts in stable chronic obstructive pulmonary disease: a systematic review and a meta-analysis. BMC Pulm Med2005;5:3.
      OpenUrlCrossRefPubMed
    10. Pinto-Plata VM, Mullerova H, Toso JF, et al. C-reactive protein in patients with COPD, control smokers and non-smokers. Thorax2006;61:23–8.
      OpenUrlAbstract/FREE Full Text
    11. ↵
      Sin DD, Lacy P, York E, et al. Effects of fluticasone on systemic markers of inflammation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med2004;170:760–5.
      OpenUrlCrossRefPubMedWeb of Science
    12. ↵
      Barnes PJ. Inhaled glucocorticoids for asthma. N Engl J Med1995;332:868–75.
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    13. ↵
      Schols AM, Wesseling G, Kester AD, et al. Dose dependent increased mortality risk in COPD patients treated with oral glucocorticoids. Eur Respir J2001;17:337–42.
      OpenUrlAbstract/FREE Full Text
    14. ↵
      Sin DD, McAlister FA, Man SF, et al. Contemporary management of chronic obstructive pulmonary disease: scientific review. JAMA2003;290:2301–12.
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • Competing interests: none declared.