CEMIT (Centro Médico Investigadores Tucumán), San Miguel de Tucumán, Tucumán, Argentina.
Ther Adv Respir Dis. 2013 Aug;7(4):225-34. doi: 10.1177/1753465813480550. Epub 2013 Feb 27.
Recently it has been suggested that there is a causal association between the use of inhaled corticosteroids (ICSs) and the risk of developing pneumonia in patients with chronic obstructive pulmonary disease (COPD). An increased risk of pneumonia associated with ICS use has been seen in trials with different design, different study populations and with evidence of a dose-response relationship. However, as none of these clinical trials were originally designed to assess pneumonia risk, radiographic confirmation of pneumonia was not always obtained. The extent to which pneumonia events have been confounded with acute exacerbations of COPD is unclear. As increased pneumonia events were not associated with increased mortality it remains unclear what the clinical significance of these findings are. Further complicating the association between ICSs and pneumonia is that meta-analyses restricted to budesonide trials have not shown an increased risk of pneumonia, and no association has been seen in patients with asthma. A number of mechanisms by which ICSs could increase the risk of pneumonia have been proposed, principally related to their immunosuppressive effect. Well-designed clinical trials with predefined endpoints and objective pneumonia definitions are needed before the real risk of pneumonia conferred by ICSs can be established. In the meantime, it seems reasonable to reduce ICSs given to COPD patients to the lowest effective doses, reduce the risk in individual patients by ensuring appropriate vaccination and to be vigilant for the possibility of pneumonia in patients with COPD on ICSs as they largely overlap with those of an acute exacerbation.
最近有研究表明，慢性阻塞性肺疾病（COPD）患者使用吸入性皮质类固醇（ICS）与肺炎风险之间存在因果关系。不同设计、不同研究人群的试验均显示 ICS 使用与肺炎风险增加相关，且存在剂量-反应关系。然而，由于这些临床试验并非专门用于评估肺炎风险，因此并非总是获得肺炎的放射影像学确诊。尚不清楚这些临床试验中有多少肺炎事件与 COPD 急性加重混淆。由于肺炎事件的增加与死亡率的增加无关，因此尚不清楚这些发现的临床意义是什么。进一步使 ICS 与肺炎之间的关联复杂化的是，仅限于布地奈德试验的荟萃分析并未显示肺炎风险增加，并且在哮喘患者中也未见关联。已经提出了 ICS 增加肺炎风险的多种机制，主要与它们的免疫抑制作用有关。在能够确定 ICS 带来的真正肺炎风险之前，需要进行具有预设终点和客观肺炎定义的精心设计的临床试验。在此期间，似乎可以合理地将 COPD 患者的 ICS 剂量降至最低有效剂量，通过确保适当的疫苗接种来降低个体患者的风险，并警惕接受 ICS 治疗的 COPD 患者出现肺炎的可能性，因为这些患者的肺炎与 COPD 急性加重的患者有很大的重叠。
