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Treating asthma or COPD with steroid inhalers raises the risk of hard-to-treat infections

Worldwide, asthma and COPD patients are commonly treated with steroid inhalers to reduce symptoms and improve lung function. However, a new study (‘The risk of mycobacterial infections associated with inhaled corticosteroid use’) suggests that these inhalers also increase the risk of lung infections caused by non-tuberculous mycobacteria, which are notoriously difficult to treat and resistant to a number of common antibiotics.

The research was led by Dr Sarah Brode, Assistant Professor of Medicine at the University of Toronto, Canada, and a staff Respirologist at the University Health Network and West Park Healthcare Centre.

“These infections are not particularly common but they are chronic and difficult to treat and are associated with an increased risk of death. Treatment typically requires at least three antibiotics given for longer than a year and this can still fail to tackle the infection,” she explained.

The study included 417,494 people with COPD or asthma aged 66 years and older, who had all been prescribed medicine for their condition at least once.

Of these patients, researchers found that 2,966 had also been diagnosed with non-tuberculous mycobacteria infections and they compared this information with whether they used a steroid inhaler, the type of steroid they had used and how much they had used it.

They found that people who were currently using steroid inhalers were around twice as likely to be diagnosed with an infection of this type and that the longer they had been taking the steroid, the greater the risk. They also discovered that one particular type of steroid, called fluticasone, was particularly risky.

Previous research has suggested that steroid inhalers hamper the body’s ability to fight infections by reducing or impairing the cells of the immune system.

Dr Brode said: “There is an ongoing debate on which patients with COPD should be treated with inhaled steroids.This research suggests that patients should discuss whether they need to use steroid inhalers with their clinicians and whether the benefits outweigh the potential harms. If they do need to use them, they should be on the lowest effective dose.

“Clinicians should carefully consider the potential benefits and harms of steroid inhalers in patients with asthma or COPD, especially those who have already had an infection of this type in the past.”

Commenting, Prof Guy Brusselle, Science Council Chair of the European Respiratory Society, said: “This is a large and important observational study on the effects of steroid inhalers in older people with asthma and COPD. Although not common, infections caused by non-tuberculous mycobacteria are serious and difficult to treat. We must consider the effects of steroid inhalers on the risk of these infections alongside their known benefits and side-effects.

“Patients who are prescribed steroid inhalers should not stop their medicine. But, if they are concerned, they should speak to their doctor about the pros and cons of the treatment and whether it is right for them.”

Dr Brode and her colleagues continue to study this group of patients and are now investigating which treatments might be most effective against non-tuberculous mycobacteria infections.

New guidance on exacerbations

A multi-disciplinary taskforce of COPD experts has published comprehensive new guidelines on the treatment of COPD exacerbations, providing new advice on the treatment of exacerbations in outpatients and the initiation of pulmonary rehabilitation during or after an exacerbation of COPD, among other topics.

The European Respiratory Society (ERS) and American Thoracic Society (ATS) collaborated to develop the new guidelines, published in the European Respiratory Journal.

Previous guidelines have relied on evidence gathered mostly from patients hospitalised with severe exacerbations, but the new document covers antibiotic and corticosteroid therapy for outpatients who experience mild and moderate exacerbations. The key points are: 1) A strong recommendation for non-invasive mechanical ventilation of patients with acute or acute-on-chronic respiratory failure; 2) Conditional recommendations for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalised patients, antibiotic therapy, home-based management, and the initiation of pulmonary rehabilitation within three weeks after hospital discharge; and 3) A conditional recommendation against the initiation of pulmonary rehabilitation during hospitalisation.

Dr Marc Miravitlles, the ERS Guidelines Director and co-author of the new guideline, commented: “This new guideline can help improve the management of exacerbations in patients with COPD. The recommendations include new advice for GPs as they refer to ambulatory patients who may experience mild or moderate exacerbations. In addition, we provide new evidence to effective strategies, such as pulmonary rehabilitation, which has been shown to improve the outcomes of exacerbated COPD patients.”

The evidence used to shape each debate was subject to comprehensive analysis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Each question is broken down in to sub-sections to detail a summary of the evidence, benefits, harms, further considerations, conclusions and research needs, wider expert opinions, ERS/ATS recommendation, remarks and values and preferences.

The authors of the guidelines state that more detailed studies should be carried out in several of the areas discussed in the paper, to enable a more comprehensive set of guidelines be produced. They also state that recommendations should be reconsidered when new evidence becomes available.

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