Clinical research study
Inhaled Corticosteroids and the Risks of Diabetes Onset and Progression

https://doi.org/10.1016/j.amjmed.2010.06.019Get rights and content

Abstract

Background

Systemic corticosteroids are known to increase diabetes risk, but the effects of high-dose inhaled corticosteroids are unknown. We assessed whether the use and dose of inhaled corticosteroids increase the risk of diabetes onset and progression.

Methods

We formed a new-user cohort of patients treated for respiratory disease during 1990-2005, identified using the Quebec health insurance databases and followed through 2007 or until diabetes onset. The subcohort treated with oral hypoglycemics was followed until diabetes progression. A nested case-control analysis was used to estimate the rate ratios of diabetes onset and progression associated with current inhaled corticosteroid use, adjusted for age, sex, respiratory disease severity, and co-morbidity.

Results

The cohort included 388,584 patients, of whom 30,167 had diabetes onset during 5.5 years of follow-up (incidence rate 14.2/1000/year), and 2099 subsequently progressed from oral hypoglycemic treatment to insulin (incidence rate 19.8/1000/year). Current use of inhaled corticosteroids was associated with a 34% increase in the rate of diabetes (rate ratio [RR] 1.34; 95% confidence interval [CI], 1.29-1.39) and in the rate of diabetes progression (RR 1.34; 95% CI, 1.17-1.53). The risk increases were greatest with the highest inhaled corticosteroid doses, equivalent to fluticasone 1000 μg per day or more (RR 1.64; 95% CI, 1.52-1.76 and RR 1.54; 95% CI, 1.18-2.02; respectively).

Conclusions

In patients with respiratory disease, inhaled corticosteroid use is associated with modest increases in the risks of diabetes onset and diabetes progression. The risks are more pronounced at the higher doses currently prescribed in the treatment of chronic obstructive pulmonary disease.

Section snippets

Data Source

We used the computerized databases of the Régie de l'assurance maladie du Québec, the agency responsible for administering the universal health insurance program of the province of Québec, Canada, for all its 7 million residents. The databases contain information on demographics and all medical services rendered, along with the diagnostic code of the service (International Classification of Diseases-9th revision), for all residents of the Province. The prescription drugs database includes

Results

The cohort included 388,584 patients treated with respiratory medications, after excluding 39,068 already treated for diabetes. At cohort entry, the patients were 50.5 (± 27.5) years of age and 46% were men. The mean duration of follow-up was 5.5 years, during which 30,167 patients initiated treatment with antidiabetic medication. Thus, the overall incidence rate of new diabetes onset was 14.2 per 1000 per year. The subcohort of patients treated exclusively with oral hypoglycemic agents

Discussion

Using a large population-based cohort of asthma and COPD patients, we found that the use of inhaled corticosteroids is associated with a significant 34% increase in the risk of incident diabetes, defined as initiation of antidiabetic medications. This risk increased with higher doses of inhaled corticosteroids, with 1000 μg of fluticasone per day or equivalent associated with 64% increase in the risk. Moreover, we found that in patients already treated for diabetes with oral hypoglycemic

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  • Cited by (0)

    Funding: This research was funded by grants from the Canadian Institutes of Health Research, Boehringer-Ingelheim GmbH, and the Canadian Foundation for Innovation. The sponsors had no role in the design and conduct of the study, including data collection, management, analysis, interpretation, or in the preparation of the manuscript.

    Conflict of Interest: Samy Suissa has received speaker fees or has served on advisory boards for AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Merck, and Pfizer. Pierre Ernst has received speaker fees or has served on advisory boards for AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Merck Frosst Canada, Novartis, and Nycomed.

    Authorship: All authors participated in the preparation of the manuscript.

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