Article Text

Download PDFPDF

Journal club
Pneumonia and inhaled corticosteroids in COPD
  1. Avais Jabbar
  1. Correspondence to Dr Avais Jabbar, Department of General Medicine, Northampton General Hospital NHS Trust, Northampton NN1 5BD, UK; ajabbar1{at}

Statistics from

Combination treatment with inhaled corticosteroids and long-acting β2-agonists decreases exacerbations and improves quality of life in patients with COPD; however; a potential concern is an increased risk of pneumonia. Although the TORCH and INSPIRE studies have shown the risk of pneumonia to increase with fluticasone/salmeterol versus placebo and tiotropium, there has been no direct comparison of fixed combinations of inhaled corticosteroids/long-acting β2-agonists.

The PATHOS study compared the occurrences of pneumonia and pneumonia-related events in patients with COPD treated with either fluticasone/salmeterol (Seretide) or budesonide/formoterol (Symbicort). This was an observational retrospective cohort study matched for propensity score comparing 2734 patients in each group. Two thousand one hundred and fifteen patients (39%) had at least one diagnosis of pneumonia during the study period. Compared with the budesonide/formoterol group, the rate of pneumonia and the rate of admission to hospital related to pneumonia were 73% and 74% higher in the fluticasone/salmeterol treatment group, giving a rate ratio of 1.73 and 1.74, respectively. When comparing fluticasone/salmeterol with budesonide/formoterol, the pneumonia event rate per 100 patient years was 11.0 versus 6.4. There were 97 deaths from pneumonia in the fluticasone/salmeterol group compared with 52 deaths in the budesonide/formoterol group, corresponding to a 76% increase in mortality. Furthermore, there was no dose–response relation with regard to risk of pneumonia with the two treatments, indicating that differences were due to the class of inhaled corticosteroids/long-acting β2-agonists and not the dose.

This study shows that the risks of pneumonia and pneumonia-related events are higher with fluticasone/salmeterol than with budesonide/formoterol in patients with COPD. This represents an intraclass difference between fixed combinations of inhaled corticosteroids/long-acting β2-agonists. Such differences may be related to differences in the immunosuppressant potencies between budesonide and fluticasone. Long-term randomised controlled trials would be beneficial to assess the extent of such intraclass differences put in context with the benefits of such regimens in preventing exacerbations.

▸ Janson C, Larsson K, Lisspers KH, et al. Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting β2 agonist: observational matched cohort study (PATHOS). BMJ 2013;346:f3306.

View Abstract

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.