Macrolide monotherapy may be a better choice than inhaled corticosteroids (ICS) to prevent acute and hospitalized respiratory infections in older patients with bronchiectasis and without comorbidities such as asthma and chronic obstructive pulmonary disease, although further studies evaluating safety and long-term effects of macrolide use should be conducted, according to a study published in the European Respiratory Journal.
Little data exist on bronchiectasis to inform treatment decisions. This new-user observational cohort study compared outcomes of ICS vs macrolide monotherapy in older US Medicare enrollees with bronchiectasis without cystic fibrosis. New use was defined as the first 28-day-plus ICS or macrolide prescription. Characteristics of the exposure cohorts were compared using standardized mean differences and a propensity score (PS) was computed to account for treatment differences. PS decile-adjusted Cox regression models were used to compare the risks for hospitalized respiratory infection, acute exacerbation, all-cause hospitalization, and mortality.
Of the 83,589 (29.3%) new ICS users, and the 6500 (2.3%) new macrolides users (out of 285,043 total Medicare enrollees with bronchiectasis), the crude hospitalized respiratory infection incidence was 12.6 per 100 patient-years for ICS and 10.3 per 100 patient-years for macrolide monotherapy. The PS-adjusted hazard ratio comparing ICS new-users to macrolide new-users was 1.39 (95% CI, 1.23-1.57) for hospitalized respiratory infection, 1.56 (95% CI, 1.49-1.64) for acute exacerbation, and 1.09 (95% CI, 0.95-1.25, not significant) for mortality.
The use of claims-based Medicare data was both a strength and limitation of the study, as it allowed for a large, real-world, population-based analysis, but prevented researchers from confirming a diagnosis of bronchiectasis and from including symptoms or severity in the study’s models and definition of acute exacerbation.
“Our results provide evidence that the widespread use of chronic ICS in older bronchiectasis patients without comorbid indications such as asthma and COPD is not supported,” the researchers concluded. “Future studies using registry or electronic health record data may be able to better group patients by comorbidities that impact therapy choice and include younger patients.”
Disclosures: The authors report personal fees or grants from Bayer and Insmed, both outside the submitted work.
Henkle E, Curtis JR, Chen L, et al. Comparative risks of chronic inhaled corticosteroids and macrolides for bronchiectasis [published online April 18, 2019]. Eur Respir J. doi:10.1183/13993003.01896-2018