Oral and Inhaled Corticosteroid Use and the Risk of Recurrent Pulmonary Embolism

The use of oral and inhaled corticosteroids is associated with a variety of adverse effects.  However, they are an accepted necessity in in the treatment of COPD, and provide necessary expansion of airways to help patients struggling to breath.  Many COPD patients suffer pulmonary embolism, and a significant proportion of these patients experience recurrent pulmonary embolism.  There is serious concern that the use of inhaled or oral corticosteroids may increase the lifetime risk of recurrent pulmonary embolism, and raise treatment related morbidity and mortality.  A recent study published in Thrombosis Research attempted to investigate a potential link between current or past use of corticosteroids and the incidence of recurrent pulmonary embolism among patients.

The researchers conducted a nested case-control study that looked at adult patients with a previous PE treated with Vitamin K antagonists.  The study analyzed 1414 PE patients, of which 384 were also later diagnosed with recurrent PE.  The study found that inhaled corticosteroid use only slightly associated with increased risk of recurrent PE, however oral medications did show increased odds of the disease.  In particular, current users of oral formulations were at increased risk (3.74 O.R., 95% CI 2.04-6.87), while past users were actually at a reduced risk (0.46 95% CI 0.28-0.74) compared to patients who never received corticosteroid therapy.  The researchers did admit the study design did not all them to discern whether the risk could be attributed solely on the medications or the underlying inflammatory disease as well.  However, they site evidence that corticosteroid medications show increased blood coagulation factors in healthy volunteers.

Inhaled and oral corticosteroids continue to be a mainstay of treatment for patients with chronic inflammatory diseases like COPD.  However, these disease states put the patients at increased risk for PE, and it would appear that the medications increase the risk of recurrent PE in the same patients.  Given the substantial risk of PE morbidity and mortality, these findings could have severe clinical impact for medication therapy of COPD and other inflammatory diseases of the pulmonary system.  As pharmacists, this association could have a large impact on the therapy management in future patients.  What steps should be taken to refine counseling points on corticosteroids, particularly in oral formulations?  Should the risk be assessed and accepted or denied on a patient-by-patient basis, or is there a better solution to the issue?

Article Link

Sneeboer, Marlous. Hutten, Barbara. Majoor, Christof. Bel, Elizabeth.  Oral and Inhaled Corticosteroid Use and the Risk of Pulmonary Embolism.  Thromres (2016); 140: 46-50.