Are COPD patients with pneumonia who are taking inhaled corticosteroids at higher risk of dying?

I n 2007, CALVERLEY et al. [1] reported the results of the TORCH (Towards a Revolution in Chronic Obstructive Pulmonary Disease Health) study, which showed that combination of salmeterol (a long-acting b-agonist (LABA)) plus fluticasone propionate (an inhaled corticosteroid (ICS)) had a trend toward a lower all-cause mortality rate in patients with chronic obstructive pulmonary disease (COPD) compared with the placebo group, with a hazard ratio of 0.825 (95% CI 0.68–1.002; p50.052). Despite the beneficial effects of ICS therapy in COPD patients, the results raised a possible safety issue regarding higher rate of community-acquired pneumonia (CAP) in the ICS groups. The probability of having pneumonia was higher among subjects receiving medications containing ICS (19.6% for ICS plus LABA and 18.3% for ICS alone) compared with the placebo group (12.3%; p,0.001) [1]. This association between ICS and pneumonia in COPD patients has also been seen in other studies: one study that examined the potential benefit of ICS and LABAs in reducing COPD mortality [1], and another comparing COPD exacerbation rates between patients receiving either salmeterol or the combination with a LABA [2, 3]. A follow-up evaluation of the TORCH study identified several risk factors associated with pneumonia, including age o55 yrs, forced expiratory volume in 1 s ,50% predicted, COPD exacerbation in the year prior to the study, worse Medical Research Council dyspnoea score and body mass index ,25 kg?m. However, mortality rate due to pneumonia was not increased among subjects treated with ICS plus LABA, but the same could not be concluded for ICS monotherapy [4]. Therefore, it was suggested that ICS use increases the risk of CAP in COPD patients; however, the CAP severity event may be milder, and it is possible that these patients could have better clinical outcomes, as suggested by MALO DE MOLINA et al. [5].