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Inhaled corticosteroids in COPD and onset of type 2 diabetes and osteoporosis: matched cohort study

Price DB, Voorham J, Brusselle G, et al.

npj Prim Care Resp Med. 2019;29(1):38.

DOI: 10.1038/s41533-019-0150-x

Identification of the most suitable chronic obstructive pulmonary disease (COPD) patients for treatment with inhaled corticosteroids (ICS) remains an important research topic. In addition, the adverse effects of ICS treatment for COPD requires further investigation. Commonly assumed adverse effects associated with ICS in COPD are pneumonia, skin bruising, oropharyngeal candidiasis, voice hoarseness and tuberculosis. Other less tenuous adverse effects include increased risk of diabetes, poor control of diabetes, fractures and decreased bone density. There is mixed evidence from cohort studies about the onset and progression of diabetes, particularly at higher ICS doses. Similarly, discordant results have been published for the association of ICS with risk of fractures. This study set out to assess the relationship between ICS treatment and diabetes onset, diabetes progression and osteoporosis onset.

This matched cohort study used two large UK databases to study patients (≥ 40 years old) initiating ICS or long-acting bronchodilator (LABA) for COPD from 1990–2015. The relationship between ICS treatment and diabetes onset (n = 17,970), diabetes progression (n = 804), and osteoporosis onset (n = 19,898) was explored by comparison with LABA treatment. The median follow-up was 3.7–5.6 years/treatment group. For patients receiving ICS, the risk of diabetes onset was significantly increased in comparison to patients receiving LABA (adjusted hazard ratio 1.27). No increased risk was found with regards to diabetes progression (adjusted hazard ratio 1.04) or the onset of osteoporosis (adjusted hazard ratio 1.13). For patients new to ICS treatment, this study found dose–response relationships for increased risk of diabetes onset, diabetes progression, and onset of osteoporosis at mean daily exposures of ≥500µg/day.

The results of this study suggest long-term ICS therapy for COPD at mean daily exposure of ≥ 500 µg is associated with an increased risk of diabetes, diabetes progression and osteoporosis. These findings add to the evidence suggesting careful attention must be applied when prescribing ICS to patients at risk of diabetes, osteoporosis and other co-morbidities and, when prescribed, ICS should be prescribed in the minimum possible dose.

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