Elevated Tuberculosis Risk in Inhaled Corticosteroid Users

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Tuberculosis risk was greater in patients with COPD than in those with asthma.
Tuberculosis risk was greater in patients with COPD than in those with asthma.

The risk of contracting tuberculosis (TB) is greater in patients who use inhaled corticosteroids (ICSs) or who have used them in the past 3 years, and the risk is even greater in patients with chronic obstructive pulmonary disease (COPD), according to a study published in The Journal of Allergy and Clinical Immunology: In Practice

Investigators conducted a 12-year, nationwide, population-based study to examine the occurrence of TB in ICS users with regard to their underlying respiratory diseases and types of ICS. The study used data from a cohort of approximately 1 million people from a Korean claims database. Adult users of budesonide or fluticasone were included. The time between last ICS prescription and TB development was examined in a nested case-controlled format,  matching for age, sex, and the initiation date of ICS use.

Overall, 175 of 17,991 ICS users developed TB during the study period. Of this number, 140 were diagnosed within 3 years of their last ICS prescription. No difference in risk for ICS-related TB was noted between budesonide and fluticasone users. Rates of TB were related to higher annual admission rates and higher comorbidity scores. TB risk was greater in patients with COPD than in those with asthma (odds ratio, 2.31; 95% CI, 1.39-3.38; =.0011).

Limitations of this study include no information about confounding factors such as smoking, TB history, or TB sequela on chest X-rays. That said, controls matched for age, sex, the date of initiation of ICS use, and adjustments for Charlson comorbidity index score and annual admission rates may have minimized the effects of confounding factors.

In additional, small numbers of patients with TB were included, particularly in subgroup analyses. A larger study is necessary to further investigate the intraclass differences in ICSs and the relative risk associated with different disease types. 

Nonetheless, the results of this study indicate that clinicians should be aware of an increased TB risk in ICS users for up to 3 years after use. 

Reference

Lee C-M, Heo J, Han S-S, et al. Inhaled corticosteroid-related tuberculosis in the real world among patients with asthma and COPD: a 10-year nationwide population-based study [published online October 16, 2018]. J Allergy Clin Immunol Pract. doi:10.1016/j.jaip.2018.10.007 

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