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Neumonías adquiridas en la comunidad en pacientes con enfermedad pulmonar obstructiva crónica tratados con corticoides inhalados u otros broncodilatadores. Estudio PNEUMOCORT
Community-acquired pneumonia in patients with chronic obstructive pulmonary disease treated with inhaled corticosteroids or other bronchodilators. Study PNEUMOCORT
Rosa Morrosa,b,c, Cristina Vediaa,b,d,
Autor para correspondencia
cvedia.bnm.ics@gencat.cat

Autor para correspondencia.
, Maria Giner-Sorianoa,b,c, Aina Casellase, Ester Amadof, Jose Miguel Baenaa,g, en representación de los investigadores del proyecto PNEUMOCORT ◊
a Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España
b Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España
c Institut Català de la Salut, Generalitat de Catalunya, Barcelona, España
d Unitat de Farmàcia, Servei d’Atenció Primària Barcelonès Nord i Maresme, Institut Català de la Salut, Badalona, España
e ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, España
f Àmbit d’Atenció Barcelona Ciutat, Institut Català de la Salut, Barcelona, España
g Centre de Salut la Marina, Institut Català de la Salut, Barcelona, España
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determinada por su gravedad&#46; Las gu&#237;as de manejo de EPOC recomiendan el uso de corticoides inhalados &#40;CI&#41; junto con broncodilatadores en pacientes con FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; y exacerbaciones repetidas<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;5</span></a>&#46; Los ensayos cl&#237;nicos en pacientes tratados con CI han demostrado reducci&#243;n de la frecuencia de exacerbaciones y mejora en la calidad de vida<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6-8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Diferentes estudios han detectado un incremento en la incidencia de neumon&#237;a en los pacientes tratados con CI<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9-14</span></a>&#46; En este contexto&#44; la Agencia Espa&#241;ola de Medicamentos y Productos Sanitarios public&#243; en 2016 una nota informativa sobre el riesgo de neumon&#237;a asociado a la administraci&#243;n de CI para el tratamiento de EPOC<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> que confirmaba un aumento de riesgo en los pacientes que reciben CI&#46; Aunque existen datos que sugieren que este riesgo se incrementar&#237;a con el aumento de dosis del CI&#44; no se puede realizar esta afirmaci&#243;n de modo concluyente&#46; Tampoco existe evidencia de diferencias en la magnitud del riesgo de neumon&#237;as entre los diferentes CI&#46; A pesar de todo&#44; la relaci&#243;n beneficio-riesgo de los CI se sigue considerando favorable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Existen estudios de cohortes y metaan&#225;lisis que no encuentran asociaciones entre utilizaci&#243;n de CI y neumon&#237;a&#44; ni mayor riesgo con el aumento de dosis de CI<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16-18</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo principal del presente estudio es analizar si los pacientes con EPOC en tratamiento con CI tienen mayor riesgo de presentar neumon&#237;a adquirida en la comunidad &#40;NAC&#41; respecto a pacientes EPOC que reciben broncodilatadores&#46; Los objetivos secundarios son analizar el riesgo de NAC seg&#250;n la dosis de CI&#44; y conocer si los pacientes en tratamiento con CI tienen mayor riesgo de presentar exacerbaciones&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dise&#241;o&#58;</span> estudio de cohortes retrospectivo de base poblacional&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Poblaci&#243;n&#58;</span> pacientes atendidos en los centros de Atenci&#243;n Primaria &#40;CAP&#41; del Institut Catal&#224; de la Salut &#40;ICS&#41; de Catalunya&#44; mayores de 45 a&#241;os&#44; diagnosticados de EPOC durante 2007-2009&#44; con antecedentes de tabaquismo&#44; y con una espirometr&#237;a realizada &#177;<span class="elsevierStyleHsp" style=""></span>1 a&#241;o del diagn&#243;stico&#46; Se excluyeron pacientes con exacerbaciones en los 6 meses previos a la inclusi&#243;n &#40;si hab&#237;an recibido al menos 2 tratamientos diferentes con corticoides orales&#41;&#44; tratados con inmunosupresores&#44; diagnosticados de asma&#44; demencia&#44; trasplantados o institucionalizados&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fuente de datos&#58;</span> Sistema de Informaci&#243;n para el Desarrollo de la Investigaci&#243;n en Atenci&#243;n Primaria &#40;SIDIAP&#41;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a>&#44; que contiene informaci&#243;n cl&#237;nica anonimizada procedente de los centros del ICS&#44; principal proveedor de servicios sanitarios en Catalunya que gestiona 279 CAP&#44; con una poblaci&#243;n de referencia de 5&#44;8 millones de personas &#40;aproximadamente el 80&#37; de la poblaci&#243;n catalana&#41;&#46; La informaci&#243;n de SIDIAP se origina en la historia cl&#237;nica electr&#243;nica del ICS &#40;ECAP&#41;&#44; e incluye datos sociodemogr&#225;ficos&#44; problemas de salud registrados mediante CIE10<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a>&#44; par&#225;metros cl&#237;nicos&#44; exploraciones&#44; h&#225;bitos t&#243;xicos&#44; datos de laboratorio&#44; prescripciones generadas por m&#233;dicos de familia y sus correspondientes datos de facturaci&#243;n de farmacia mediante c&#243;digos ATC<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a>&#46; SIDIAP se puede cruzar con el conjunto m&#237;nimo de datos de hospitalizaciones de agudos &#40;CMBD-HA&#41;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a>&#44; que contiene los diagn&#243;sticos codificados con CIE9<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> de las altas hospitalarias en hospitales p&#250;blicos&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Formaci&#243;n de las cohortes&#58;</span> la inclusi&#243;n en la cohorte fue al inicio del tratamiento inhalado&#46; Se formaron dos cohortes&#59; pacientes que inician tratamiento con CI y pacientes no iniciadores de CI &#40;NCI&#41; que inician tratamiento con &#946;-adren&#233;rgicos o anticolin&#233;rgicos de larga duraci&#243;n &#40;LABA o LAMA&#41; en un periodo &#177;<span class="elsevierStyleHsp" style=""></span>6 meses del diagn&#243;stico&#46; Ambas cohortes se siguieron hasta final de 2011&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Variables&#58;</span> sociodemogr&#225;ficas&#44; tabaquismo &#40;fumador&#44; exfumador&#44; o situaci&#243;n actual desconocida&#41;&#44; consumo de alcohol&#44; antecedentes patol&#243;gicos&#44; neumon&#237;a &#40;c&#243;digos CIE9&#58; 480 a 487&#41; y bronquitis &#40;c&#243;digos CIE9&#58; 466&#44; 490&#44; 491&#44; 494&#46;0 y 494&#46;1&#41; en los 2 a&#241;os previos&#44; vacunaciones &#40;gripe&#44; neumoc&#243;cica&#41;&#44; tratamientos farmacol&#243;gicos para el sistema respiratorio &#40;&#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos&#44; anticolin&#233;rgicos&#44; CI&#44; corticoides orales y antibi&#243;ticos&#41;&#44; y tratamientos relacionados con aparici&#243;n de neumon&#237;as &#40;benzodiacepinas y antiulcerosos&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">ECAP no posibilita el registro de gravedad de la EPOC&#46; Por ello se categoriz&#243; en funci&#243;n del consumo de f&#225;rmacos inhalados &#40;&#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos&#44; anticolin&#233;rgicos&#44; o CI&#41;&#46; La EPOC se clasific&#243; como leve si recib&#237;an &#60;<span class="elsevierStyleHsp" style=""></span>50&#37; de la dosis diaria definida &#40;DDD&#41; te&#243;rica de alg&#250;n tratamiento broncodilatador&#59; moderada si recib&#237;an &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37; de un tratamiento&#59; grave si recib&#237;an &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37; de 2 tratamientos&#44; y muy grave si recib&#237;an &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37; de 3 tratamientos&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Los diagn&#243;sticos de NAC se obtuvieron de los informes del CMBD-HA&#46; Las exacerbaciones no siempre se registraban en ECAP&#44; por lo que se definieron como graves aquellas que implicaban ingreso hospitalario y se obten&#237;an del CMBD-HA&#44; y leves cuando el&#47;la paciente ten&#237;a datos de facturaci&#243;n de farmacia de un tratamiento antibi&#243;tico indicado en infecciones respiratorias y un corticoide oral durante el mismo periodo de tiempo&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exposici&#243;n a f&#225;rmacos&#58;</span> a partir de las recetas facturadas se calcularon las dosis de tratamientos en DDD&#46; Se estratificaron los consumos en funci&#243;n del n&#250;mero de DDD del te&#243;rico esperado que hab&#237;an de recibir los pacientes&#46; La exposici&#243;n a &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos y anticolin&#233;rgicos se estratific&#243; en 3 grupos&#58; sin tratamiento&#44; &#60;<span class="elsevierStyleHsp" style=""></span>50&#37; de DDD te&#243;ricas&#44; y &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#46; La exposici&#243;n a CI se estratific&#243; en 4 grupos seg&#250;n DDD&#58; &#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#44; 40-80&#37;&#44; 80-120&#37; y &#62;<span class="elsevierStyleHsp" style=""></span>120&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#225;lculo del tama&#241;o de muestra&#58;</span> se incluyeron todos los pacientes de SIDIAP que cumpl&#237;an criterios de inclusi&#243;n y ninguno de exclusi&#243;n&#46; La muestra se calcul&#243; aceptando un riesgo alfa de 0&#44;05 y un riesgo beta de 0&#44;20 en un contraste bilateral&#44; para detectar al menos un riesgo relativo de 1&#44;6&#44; considerando una tasa de enfermos en el grupo de no expuestos a CI de 46&#44;6 casos&#47;1&#46;000 personas-a&#241;o<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a>&#46; Se precisaban 1&#46;529 sujetos por grupo&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">An&#225;lisis estad&#237;stico&#58;</span> para valorar la comparabilidad de las caracter&#237;sticas basales entre cohortes se utiliz&#243; el test de Chi cuadrado o el test t de Student seg&#250;n el tipo de variable&#44; empleando las pruebas no param&#233;tricas correspondientes si no se cumpl&#237;an las condiciones de aplicaci&#243;n&#46; Se calcul&#243; la densidad de incidencia de NAC y exacerbaciones para las cohortes estudiadas&#46; Se estudi&#243; el riesgo de presentarlas mediante regresi&#243;n de Cox&#44; expresando el resultado en forma de <span class="elsevierStyleItalic">hazard ratio</span> &#40;HR&#41; y su intervalo de confianza &#40;IC&#41; del 95&#37;&#44; ajustando el efecto por las variables&#58; sexo&#44; edad&#44; patolog&#237;as concomitantes&#44; h&#225;bitos tab&#225;quico y en&#243;lico&#44; tratamiento basal respiratorio y otros tratamientos&#44; antecedentes de exacerbaciones&#44; neumon&#237;as y gravedad de la EPOC&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Debido a la gran inestabilidad de las cohortes&#44; porque gran parte de los pacientes que no iniciaban CI los recibieron en mayor o menor medida durante el seguimiento&#44; no se pudo realizar el an&#225;lisis por protocolo ya que el n&#250;mero de pacientes que se manten&#237;an en la cohorte inicial de NCI era excesivamente bajo&#44; por lo que solo se realiz&#243; un an&#225;lisis por intenci&#243;n de tratar&#46; Se realiz&#243; un an&#225;lisis de supervivencia para determinar el efecto de exposici&#243;n a CI en la incidencia de neumon&#237;as y exacerbaciones&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Se usaron los programas R &#40;versi&#243;n 2&#46;10&#46;1&#41; y Stata&#47;SE versi&#243;n 11 para Windows &#40;Stata Corp&#46;&#44; College Station&#44; Texas&#44; EE&#46;<span class="elsevierStyleHsp" style=""></span>UU&#46;&#41;&#46;<elsevierMultimedia ident="fig0005"></elsevierMultimedia></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><p id="par0090" class="elsevierStylePara elsevierViewall">De 2007 a 2009&#44; hab&#237;a 35&#46;381 pacientes &#8805;<span class="elsevierStyleHsp" style=""></span>45 a&#241;os diagnosticados de EPOC en SIDIAP con antecedentes de tabaquismo&#44; de los cuales se excluyeron el 89&#44;2&#37;&#46; Se incluyeron 3&#46;837 pacientes&#58; 2&#46;224 &#40;58&#44;0&#37;&#41; en la cohorte CI y 1&#46;613 &#40;42&#44;0&#37;&#41; en la NCI&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra las caracter&#237;sticas sociodemogr&#225;ficas y cl&#237;nicas basales de los pacientes incluidos&#59; el 87&#44;2&#37; eran varones&#44; con una edad media de 65 a&#241;os&#46; Los pacientes con CI eran mayores&#46; En el momento del diagn&#243;stico de la EPOC&#44; el 48&#44;1&#37; eran fumadores y el 42&#44;2&#37; eran exfumadores&#44; con menor frecuencia de fumadores en la cohorte CI &#40;45&#44;9&#37; vs&#46; 51&#44;1&#37;&#41;&#46; Los pacientes del grupo CI hab&#237;an presentado bronquitis previas con mayor frecuencia que los del grupo NCI &#40;5&#44;4&#37; vs&#46; 2&#44;5&#37;&#41;&#46; En la cohorte CI hab&#237;a m&#225;s pacientes con EPOC grave y muy grave&#46; No se observaron diferencias en los antecedentes de vacunaciones&#46; La cohorte CI presentaba mayor consumo previo de corticoides orales&#44; benzodiacepinas y antiulcerosos&#46; Los pacientes de la cohorte CI recib&#237;an mayores dosis de &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos y los de la cohorte NCI recib&#237;an m&#225;s anticolin&#233;rgicos&#46; Sobre el tratamiento CI&#44; el 58&#37; de los pacientes iniciaban tratamiento con budesonida&#46; Del grupo NCI&#44; 570 &#40;35&#44;3&#37;&#41; pacientes recibieron CI en alg&#250;n momento durante el seguimiento&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> muestra las incidencias de neumon&#237;a y exacerbaciones por 100 pacientes&#47;a&#241;o&#46; Se detectaron 230 casos de neumon&#237;a&#44; siendo superior la incidencia en el grupo CI &#40;2&#44;18&#59; IC 95&#37;&#58; 1&#44;87-2&#44;55&#41; que en el NCI &#40;1&#44;37&#59; IC 95&#37;&#58; 1&#44;09-1&#44;72&#41;&#46; Tambi&#233;n se detectaron incidencias superiores de exacerbaciones graves y leves en la cohorte CI respecto a la NCI&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0010">figura 1</a> se muestra el tiempo entre la entrada a la cohorte y la aparici&#243;n del primer episodio de NAC &#40;log rank test&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La media fue de 555&#44;2 d&#237;as &#40;DE&#58; 440&#44;8&#41;&#44; sin diferencias entre grupos&#46; Para las exacerbaciones graves hubo diferencias&#59; en el grupo CI fue de 411&#44;5 d&#237;as &#40;439&#44;5&#41; y en el NCI fue de 580&#44;3 d&#237;as &#40;499&#44;0&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> detalla los factores de riesgo asociados a la aparici&#243;n de NAC y de exacerbaciones&#46; En el modelo ajustado por las variables&#44; el HR de presentar NAC en la cohorte CI respecto a la NCI fue de 1&#44;17 &#40;IC 95&#37;&#58; 0&#44;87-1&#44;56&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;295&#41;&#46; Las variables que mostraron una asociaci&#243;n positiva significativa fueron&#58; edad&#44; DM2&#44; antecedentes de neumon&#237;as y bronquitis&#44; EPOC muy grave&#44; tratamiento con &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos y con anticolin&#233;rgicos a dosis bajas&#44; y tratamiento previo con corticoides orales&#46; Hubo una asociaci&#243;n inversa con el sexo&#59; las mujeres presentaban menor riesgo de NAC&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Para las exacerbaciones graves&#44; las variables que mostraron una asociaci&#243;n positiva fueron&#58; edad&#44; tabaquismo&#44; DM2&#44; antecedentes de neumon&#237;as y bronquitis&#44; EPOC grave y muy grave&#44; tratamiento con &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos a dosis bajas y con anticolin&#233;rgicos a cualquier dosis&#44; y tratamiento previo con corticoides orales&#46; Las mujeres presentaban menor riesgo de exacerbaciones graves&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Para las exacerbaciones leves&#44; el HR en la cohorte de CI respecto a la de NCI fue de 1&#44;28 &#40;IC 95&#37;&#58; 1&#44;10-1&#44;50&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41; y las variables asociadas fueron&#58; edad&#44; sexo masculino&#44; vacunaci&#243;n antineumoc&#243;cica previa&#44; EPOC grave y muy grave&#44; tratamiento con &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos a dosis bajas y con anticolin&#233;rgicos a cualquier dosis&#44; y tratamiento previo con corticoides orales&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 2</a> se presentan incidencias de NAC y exacerbaciones en las dos cohortes seg&#250;n las dosis de exposici&#243;n a CI durante el seguimiento&#46; Para los 3 eventos se observa un aumento de la tasa de incidencia a medida que aumenta la dosis de CI&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0130" class="elsevierStylePara elsevierViewall">Se analiz&#243; la incidencia de NAC en pacientes inicialmente tratados con CI en comparaci&#243;n con los que no iniciaron CI&#46; En el an&#225;lisis ajustado&#44; la cohorte CI no demostr&#243; una tasa significativamente superior de NAC respecto a NCI&#46; Las variables que se asociaron con el aumento de riesgo de NAC fueron&#58; edad&#44; DM2&#44; antecedentes de neumon&#237;as y bronquitis&#44; tratamientos con &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos o anticolin&#233;rgicos a dosis bajas&#44; tratamiento previo con corticoides orales y gravedad de la EPOC&#46; Las mujeres presentaron menor riesgo&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Los ensayos cl&#237;nicos TORCH<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> o INSPIRE<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> observaron incrementos en la incidencia de neumon&#237;as en pacientes EPOC tratados con CI&#46; El metaan&#225;lisis de Kew y Seniukovich<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> incluy&#243; 43 estudios de 2002-2013 que evaluaban el riesgo de neumon&#237;a asociado a CI en 31&#46;314 pacientes EPOC&#59; los autores concluyen que los CI en monoterapia o asociados a LABA aumentan el riesgo de presentar neumon&#237;a&#44; aunque sin afectar a la supervivencia&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Varios estudios de cohortes han evaluado el riesgo de NAC en pacientes con EPOC tratados con CI&#46; Lin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> incluyeron pacientes diagnosticados de EPOC y evaluaron los factores asociados a la aparici&#243;n de neumon&#237;as&#44; que fueron&#58; edad&#44; menor FEV<span class="elsevierStyleInf">1</span>&#44; exacerbaciones frecuentes&#44; enfermedad cardiovascular previa y tratamiento con CI&#46; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> encontraron asociaci&#243;n entre el uso de CI y neumon&#237;a&#44; junto con factores como edad&#44; sexo masculino&#44; DM2&#44; neumon&#237;as previas o uso reciente de corticoides orales&#46; La mayor&#237;a de las variables asociadas a neumon&#237;a en estos estudios tambi&#233;n muestran asociaci&#243;n en nuestro trabajo&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En otro estudio de cohortes de 163&#46;514 pacientes EPOC tratados en 1990-2005 en Canad&#225;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a>&#44; el tratamiento con CI se asoci&#243; con un aumento del riesgo relativo de neumon&#237;a &#40;RR&#58; 1&#44;69&#59; IC 95&#37;&#58; 1&#44;63-1&#44;75&#41;&#44; que disminu&#237;a progresivamente cuando se suspend&#237;a el tratamiento con CI y desaparec&#237;a a los 6 meses &#40;RR&#58; 1&#44;08&#59; IC 95&#37;&#58; 0&#44;99-1&#44;17&#41;&#46; En un estudio caso-control anidado en una cohorte de EPOC<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#44; se analizaron las recurrencias de neumon&#237;a en pacientes mayores de 65 a&#241;os&#46; El uso de CI se asoci&#243; con un aumento del 90&#37; de recurrencias &#40;OR&#58; 1&#44;90&#59; IC 95&#37;&#58; 1&#44;45-2&#44;50&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Otros estudios no han encontrado asociaci&#243;n entre CI y aumento de riesgo de NAC&#46; La revisi&#243;n de Iannella et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> incluy&#243; ensayos cl&#237;nicos y estudios de cohortes&#44; y detect&#243; una asociaci&#243;n entre tratamiento con CI y neumon&#237;a&#44; aunque no pueden establecer relaci&#243;n causal debido a diferentes sesgos&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En referencia a las exacerbaciones&#44; los CI est&#225;n indicados para reducir su frecuencia y suelen ser pacientes con una EPOC m&#225;s evolucionada&#46; En nuestro estudio&#44; el riesgo de exacerbaciones graves no fue diferente entre grupos&#44; aunque estas aparec&#237;an significativamente antes en la cohorte de CI&#46; Las variables asociadas a presentar exacerbaciones graves fueron&#58; edad&#44; tabaquismo&#44; DM2&#44; neumon&#237;as y bronquitis previas&#44; EPOC grave y muy grave&#44; &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos a dosis bajas&#44; anticolin&#233;rgicos a cualquier dosis y tratamiento previo con corticoides sist&#233;micos&#46; Las mujeres presentaron menor riesgo de exacerbaciones graves&#44; aunque mayor para exacerbaciones leves&#46; El riesgo de exacerbaciones leves fue superior en el grupo CI en comparaci&#243;n con NCI&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En un metaan&#225;lisis de 11 estudios que comparaban el uso de LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA con LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CI en 9&#46;839 pacientes con EPOC&#44; los pacientes con LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA presentaron menos exacerbaciones que los que recibieron CI<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a>&#46; En otro estudio en 2&#46;113 pacientes con EPOC&#44; tambi&#233;n se observ&#243; mayor tasa de exacerbaciones en pacientes tratados con CI respecto a los no tratados<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Existen varias limitaciones en nuestro estudio referentes al tipo de datos&#44; que dificultan la generalizaci&#243;n de los resultados&#46; Sobre el diagn&#243;stico de EPOC&#44; a parte del registro en SIDIAP&#44; era criterio de inclusi&#243;n que los pacientes tuviesen realizada una espirometr&#237;a &#177;<span class="elsevierStyleHsp" style=""></span>1 a&#241;o del diagn&#243;stico&#44; ya que hab&#237;a posibilidad de infrarregistro diagn&#243;stico o de codificaci&#243;n incorrecta&#46; Tambi&#233;n se excluyeron los pacientes que ten&#237;an registrado el diagn&#243;stico durante 2007-2009 pero recib&#237;an tratamiento inhalado previamente&#46; En cuanto a la gravedad de la enfermedad&#44; que no era posible registrarla en ECAP&#44; recurrimos a una aproximaci&#243;n mediante la dosis de f&#225;rmacos inhalados&#46; No se pudo utilizar valores de FEV<span class="elsevierStyleInf">1</span>&#44; porque no se registraban los resultados de la espirometr&#237;a&#46; No se dispone de datos de cumplimiento del tratamiento inhalado&#44; &#250;nicamente de datos de dispensaci&#243;n en oficinas de farmacia&#46; Tambi&#233;n hab&#237;a posibilidad de infrarregistro de las exacerbaciones leves&#44; por lo que se definieron seg&#250;n el tratamiento recibido&#46; Las comorbilidades se analizaron en el momento de entrada a la cohorte para caracterizar a los pacientes incluidos&#46; Todas estas situaciones&#44; y el car&#225;cter observacional del estudio&#44; no permiten establecer una relaci&#243;n causal entre el uso de CI y la aparici&#243;n de NAC y exacerbaciones en pacientes con EPOC&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">La principal fortaleza de nuestro estudio es la representatividad de los datos&#44; pues SIDIAP incluye aproximadamente el 80&#37; de la poblaci&#243;n catalana&#44; y que estos datos son procedentes de la pr&#225;ctica cl&#237;nica diaria&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusiones</span><p id="par0175" class="elsevierStylePara elsevierViewall">No se observaron diferencias significativas entre las cohortes en el riesgo de NAC&#46; El tiempo hasta el primer episodio de NAC no difer&#237;a significativamente entre grupos&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">El riesgo de exacerbaciones graves tampoco fue diferente entre grupos&#44; aunque estas aparec&#237;an significativamente antes en el grupo CI&#46; El riesgo de exacerbaciones leves fue superior en el grupo CI&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Tanto NAC como exacerbaciones graves fueron m&#225;s frecuentes en pacientes con EPOC grave y en pacientes tratados con dosis altas de CI&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financiaci&#243;n</span><p id="par0225" class="elsevierStylePara elsevierViewall">&#171;Neumon&#237;as adquiridas en la comunidad en pacientes con enfermedad pulmonar obstructiva cr&#243;nica tratados con corticoides inhalados u otros broncodilatadores&#46; Estudio PNEUMOCORT&#187; recibi&#243; financiaci&#243;n del Ministerio de Sanidad&#44; Pol&#237;tica Social e Igualdad a trav&#233;s de la convocatoria de ayudas para proyectos de investigaci&#243;n cl&#237;nica de car&#225;cter no comercial con medicamentos del Instituto Carlos III de 2010 &#40;EC10-081&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicto de intereses</span><p id="par0230" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar el riesgo de neumon&#237;a y&#47;o exacerbaciones en pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; tratados con corticoides inhalados &#40;CI&#41; y no tratados con CI &#40;NCI&#41;&#46; Estimar el riesgo de neumon&#237;a seg&#250;n la dosis de CI&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes de base poblacional&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Emplazamiento</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Atenci&#243;n Primaria&#46; Institut Catal&#224; de la Salut&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participantes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes &#8805;<span class="elsevierStyleHsp" style=""></span>45 a&#241;os diagnosticados de EPOC entre 2007 y 2009 en el Sistema de Informaci&#243;n para el Desarrollo de la Investigaci&#243;n en Atenci&#243;n Primaria &#40;SIDIAP&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dos cohortes&#59; pacientes que inician CI y pacientes que inician broncodilatadores NCI despu&#233;s del diagn&#243;stico de EPOC&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Mediciones principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Sociodemogr&#225;ficas&#44; tabaquismo&#44; antecedentes patol&#243;gicos&#44; neumon&#237;as&#44; exacerbaciones&#44; vacunaciones y tratamientos farmacol&#243;gicos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 3&#46;837 pacientes&#58; el 58&#37; en el grupo CI y el 42&#37; en el grupo NCI&#46; Se detectaron incidencias superiores de neumon&#237;a y exacerbaciones en el grupo CI respecto al NCI &#40;2&#44;18 vs&#46; 1&#44;37&#41;&#46; El riesgo de neumon&#237;a y de exacerbaciones graves no fue significativamente diferente entre grupos&#58; HR de 1&#44;17 &#40;IC 95&#37;&#58; 0&#44;87-1&#44;56&#41; y de 1&#44;06 &#40;IC 95&#37;&#58; 0&#44;87-1&#44;31&#41;&#44; respectivamente&#46; En el grupo CI presentaron mayor riesgo de exacerbaciones leves&#44; con HR de 1&#44;28 &#40;IC 95&#37;&#58; 1&#44;10-1&#44;50&#41;&#46; Las variables asociadas a mayor riesgo de neumon&#237;as fueron&#58; edad&#44; diabetes&#44; neumon&#237;as y bronquitis previas&#44; EPOC muy grave&#44; tratamiento con &#946;<span class="elsevierStyleInf">2</span>-adren&#233;rgicos o anticolin&#233;rgicos a dosis bajas&#44; y tratamiento previo con corticoides orales&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No hubo diferencias entre cohortes en el riesgo de NAC ni exacerbaciones graves&#46; Las exacerbaciones leves fueron superiores en el grupo CI&#46; Tanto NAC como exacerbaciones graves fueron m&#225;s frecuentes en pacientes con EPOC grave y en pacientes tratados con dosis altas de CI&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objectives</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To analyse the risk of pneumonia and&#47;or exacerbations in patients with chronic obstructive pulmonary disease &#40;COPD&#41; who receive treatment with inhaled corticosteroids &#40;CI&#41;&#44; in comparison with those who are not treated with inhaled corticosteroids &#40;NCI&#41;&#46; To estimate the risk of pneumonia according to CI dose&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Population-based cohort study&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Primary Healthcare&#46; <span class="elsevierStyleItalic">Institut Catal&#224; de la Salut&#46;</span></p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Participants</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patients &#8805;<span class="elsevierStyleHsp" style=""></span>45 years-old diagnosed with COPD between 2007 and 2009 in the Information System for Research in Primary Care &#40;SIDIAP&#41;&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervention</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Two cohorts&#59; patients initiating CI and patients initiating bronchodilators after COPD diagnosis&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Main measurements</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Demographics&#44; smoking&#44; medical history&#44; pneumonias&#44; exacerbations&#44; vaccinations&#44; and drug therapy&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A total of 3&#44;837 patients were included&#44; 58&#37; in the CI and 42&#37; in the NCI group&#46; Higher incidence rates of pneumonia and exacerbations were detected in the CI group compared with the NCI &#40;2&#46;18 vs&#46; 1&#46;37&#41;&#46; The risk of pneumonia and severe exacerbations was not significantly different between groups&#44; HR&#59; 1&#46;17 &#40;95&#37; CI&#59; 0&#46;87-1&#46;56&#41; and 1&#46;06 &#40;95&#37; CI&#59; 0&#46;87-1&#46;31&#41;&#44; respectively&#46; Patients in the CI group had a higher risk of mild exacerbations&#44; HR&#59; 1&#46;28 &#40;95&#37; CI&#59; 1&#46;10-1&#46;50&#41;&#46; Variables associated with a higher risk of pneumonia were age&#44; diabetes&#44; previous pneumonias and bronchitis&#44; very severe COPD&#44; treatment with low doses of &#946;<span class="elsevierStyleInf">2</span>-adrenergic or anticholinergic agents&#44; and previous treatment with oral corticosteroids&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">There were no differences between cohorts in the risk of pneumonia and severe exacerbations&#46; The risk of mild exacerbations was higher in the CI group&#46; Pneumonias and severe exacerbations were more frequent in patients with severe COPD and in patients receiving high doses of CI&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Los investigadores del proyecto PNEUMOCORT se relacionan en el <a class="elsevierStyleCrossRef" href="#sec0050">anexo</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Presentaciones a congresos&#58; Vedia C&#44; Plana-Ripoll O&#44; Pera H&#44; Morros R&#44; Almeda J&#44; Amado E&#46; Neumon&#237;as adquiridas en la comunidad en pacientes con enfermedad pulmonar obstructiva cr&#243;nica tratados con corticoides inhalados u otros broncodilatadores &#40;Estudio PNEUMOCORT&#41;&#46; Primera fase&#58; formaci&#243;n de las cohortes y datos basales&#46; XXV Congreso de la Sociedad Espa&#241;ola de Farmacolog&#237;a Cl&#237;nica&#46; 28&#47;09&#47;2012&#44; Alicante&#46;</p> <p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleSup">&#9734;&#9734;</span> Vedia C&#44; Casellas A&#44; Pera H&#44; Amado E&#44; Morros R&#44; Almeda J&#44; Baena JM&#44; Rosell M&#44; Rodr&#237;guez MT&#44; Elorza JM&#46; P&#243;ster&#46; Exacerbaciones en pacientes con enfermedad pulmonar obstructiva cr&#243;nica tratados con corticoides inhalados&#46; XXVI Congreso de la Sociedad Espa&#241;ola de Farmacolog&#237;a Cl&#237;nica&#46; 17&#47;10&#47;2013&#44; C&#225;diz&#46;</p>"
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            "apendice" => "<p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jes&#250;s Almeda</span>&#44; Universitat Aut&#242;noma de Barcelona&#44; Bellaterra&#44; Cerdanyola del Vall&#232;s&#46; Unitat de Suport a la Recerca Metropolitana Sud&#44; Institut Universitari d&#8217;Investigaci&#243; en Atenci&#243; Prim&#224;ria Jordi Gol &#40;IDIAP Jordi Gol&#41;&#44; Cornell&#224; de Llobregat&#44; Espa&#241;a&#46; CIBER de Epidemiolog&#237;a y Salud P&#250;blica CIBERESP&#46;</p> <p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Teresa Rodr&#237;guez</span>&#44; Institut Universitari d&#8217;Investigaci&#243; en Atenci&#243; Prim&#224;ria Jordi Gol &#40;IDIAP Jordi Gol&#41;&#44; Barcelona&#46; Universitat Aut&#242;noma de Barcelona&#44; Bellaterra&#44; Cerdanyola del Vall&#232;s&#44; Espa&#241;a&#46;</p> <p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Oleguer Plana-Ripoll</span>&#44; Section of Epidemiology&#44; Department of Public Health&#44; Aarhus University&#44; Aarhus&#44; Dinamarca</p> <p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Helena Pera</span>&#44; Institut Universitari d&#8217;Investigaci&#243; en Atenci&#243; Prim&#224;ria Jordi Gol &#40;IDIAP Jordi Gol&#41;&#44; Barcelona&#46; Universitat Aut&#242;noma de Barcelona&#44; Bellaterra&#44; Cerdanyola del Vall&#232;s&#46; Espa&#241;a&#46;</p> <p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Magdalena Rosell</span>&#44; Unitat Docent Metropolitana Nord&#44; Sabadell&#44; Espa&#241;a&#46;</p> <p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jose M&#46; Elorza</span>&#44; CAP Ripollet&#44; Servei d&#8217;Atenci&#243; Prim&#224;ria Vall&#232;s Occidental&#46; Direcci&#243; d&#8217;Atenci&#243; Prim&#224;ria Metropolitana Nord&#44; Institut Catal&#224; de la Salut&#44; Sabadell&#44; Espa&#241;a&#46;</p> <p id="par0265" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pere Toran</span>&#44; Universitat Aut&#242;noma de Barcelona&#44; Bellaterra&#44; Cerdanyola del Vall&#232;s&#46; Unitat de Suport a la Recerca Metropolitana Nord&#44; Institut Universitari d&#8217;Investigaci&#243; en Atenci&#243; Prim&#224;ria Jordi Gol &#40;IDIAP Jordi Gol&#41;&#44; Matar&#243;&#44; Espa&#241;a&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad EPOC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">655 &#40;29&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Muy grave&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">865 &#40;22&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamientos 3 meses previos</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Corticoides orales&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Benzodiacepinas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">760 &#40;19&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antiulcerosos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1391 &#40;36&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">837 &#40;37&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">554 &#40;34&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento con &#946;</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">-adren&#233;rgicos</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">825 &#40;51&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Salmeterol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">433 &#40;26&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Formoterol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">694 &#40;31&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">397 &#40;24&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento con anticolin&#233;rgicos</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;763 &#40;45&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">869 &#40;39&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">894 &#40;55&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tiotropio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;134 &#40;29&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">433 &#40;19&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">701 &#40;43&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ipratropio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">667 &#40;17&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">458 &#40;20&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">209 &#40;13&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento con CI</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;223 &#40;100&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;223 &#40;100&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Beclometasona&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">160 &#40;7&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">160 &#40;7&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Budesonida&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;290 &#40;58&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;290 &#40;58&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">810 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tasa 100 personas&#47;a&#241;o &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">156&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;18 &#40;1&#44;87-2&#44;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;37 &#40;1&#44;09-1&#44;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exacerbaciones graves&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">309&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;54 &#40;4&#44;06-5&#44;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#44;90 &#40;2&#44;47-3&#44;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Exacerbaciones leves&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;14 &#40;7&#44;47-8&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">260&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#44;14 &#40;4&#44;55-5&#44;80&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Variables de ajuste&#58; sexo&#44; edad&#44; patolog&#237;as concomitantes&#44; h&#225;bitos tab&#225;quico y en&#243;lico&#44; tratamiento basal respiratorio y otros tratamientos&#44; antecedentes de exacerbaciones&#44; neumon&#237;as y gravedad de la EPOC&#46;</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">CI&#58; corticoides inhalados&#59; EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; HR&#58; <span class="elsevierStyleItalic">hazard ratio</span>&#59; IC&#58; intervalo de confianza&#59; NAC&#58; neumon&#237;a adquirida en la comunidad&#59; NCI&#58; no corticoides inhalados&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">En negrita se muestran los resultados estad&#237;sticamente significativos&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cohorte CI &#40;referencia NCI&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;17 &#40;0&#44;87-1&#44;56&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Fumador &#40;ref&#46; exfumador&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;97 &#40;0&#44;72-1&#44;30&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;833&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes mellitus</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Neumon&#237;a previa</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;366&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Bronquitis previa</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;092&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n gripe</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;49 &#40;0&#44;56-3&#44;92&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;26 &#40;0&#44;72-2&#44;23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;416&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Vacunaci&#243;n neumococo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;28 &#40;0&#44;79-2&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;320&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;14 &#40;0&#44;82-1&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;445&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;32 &#40;1&#44;04-1&#44;68&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;024</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad EPOC &#40;ref&#46; leve&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Esquema del estudio</span>&#46; Estudio de cohortes para analizar el riesgo de neumon&#237;a y&#47;o exacerbaciones en pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; tratados con corticoides inhalados &#40;CI&#41; y no tratados con CI &#40;NCI&#41;&#46;</p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Lo conocido sobre el tema</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Las gu&#237;as de manejo de EPOC recomiendan el uso de corticoides inhalados &#40;CI&#41; en pacientes con EPOC de car&#225;cter grave y exacerbaciones repetidas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">El uso de corticoides inhalados se ha relacionado con la aparici&#243;n de neumon&#237;as en pacientes con EPOC&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Qu&#233; aporta este estudio</span><p id="par0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Analiza el riesgo de presentar neumon&#237;a y exacerbaciones en pacientes EPOC que inician tratamiento con corticoides inhalados &#40;CI&#41; respecto a los que inician tratamiento broncodilatador en la pr&#225;ctica cl&#237;nica habitual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">No se han encontrado diferencias en el riesgo de neumon&#237;as en los pacientes EPOC que inician CI&#46; El riesgo de exacerbaciones graves tampoco fue diferente&#44; y el de exacerbaciones leves fue superior en los que recib&#237;an CI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Tanto las neumon&#237;as como las exacerbaciones graves fueron m&#225;s frecuentes en pacientes con EPOC grave y en los tratados con dosis altas de CI&#46;</p></li></ul></p></span></span>"
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Información del artículo
ISSN: 02126567
Idioma original: Español
DOI:10.1016/j.aprim.2018.02.007
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