Effects of inhaled corticosteroids on mortality and hospitalisation in elderly asthma and chronic obstructive pulmonary disease patients : Appraising the evidence

Asthma and chronic obstructive pulmonary disease (COPD) are common conditions that have substantial effects on daily functioning and medical resource utilisation. In elderly populations, the use of inhaled corticosteroids (ICS) as a mainstay of treatment in asthma has long been accepted whereas the appropriateness and extent of use of ICS in COPD is not as clear. This paper reviews data associated with ICS treatment in the elderly, specifically characteristics of ICS users, rates of adherence, hospitalisation and mortality associated with ICS treatment. Studies examining the use of ICS in asthma and COPD have generally found that ICS may be underused compared with guideline recommendations or that there are substantial differences between patients who receive ICS and those who do not. Among elderly asthma or COPD patients who receive ICS, there are lower rates of hospitalisation among those who adhere to their treatment plan. Among elderly patients with asthma, the combination of ICS plus long-acting beta-adrenoceptor agonists has been shown to be superior in terms of mortality and hospitalisation compared with either treatment alone. There may be an interaction effect between oral corticosteroids and ICS among elderly COPD patients, although important differences may be present in the clinical characteristics of patients who receive one versus both forms of corticosteroids. A dose-response relationship between ICS and both all-cause and pulmonary-specific mortality has been shown among older COPD patients. Several existing studies are subject to selection bias, as they have identified patients who survived for a specified period, for example, long enough to have received a specified number of prescriptions for ICS. This bias must be further explored. Future research should also clearly delineate asthma and COPD populations in order to identify different benefits from ICS. The use of a claims database that also includes clinical metrics would be useful to identify additional possible outcomes of ICS use. Further, symptom diaries or other patient-reported outcomes, such as health-related quality of life and health status, should be included in studies of ICS among the elderly to identify other benefits that should be considered in treatment selection.