Should inhaled corticosteroids be initiated or continued in a patient with acute community‑acquired pneumonia, especially if they have asthma or COPD?

Inhaled Corticosteroids in Pneumonia

Continue inhaled corticosteroids (ICS) in patients with asthma or COPD who develop community-acquired pneumonia, but do not initiate ICS as treatment for the pneumonia itself.

Guideline Position on Systemic Corticosteroids in CAP

The 2019 IDSA/ATS guidelines provide clear direction: do not routinely use corticosteroids in adults with nonsevere CAP (strong recommendation, high-quality evidence), and do not routinely use corticosteroids in adults with severe CAP (conditional recommendation, moderate-quality evidence) 1. The exception is patients with CAP and refractory septic shock, where the Surviving Sepsis Campaign recommendations apply 1.

For severe CAP specifically, some evidence suggests benefit in select populations—particularly those with elevated CRP >150 mg/L and septic shock requiring vasopressors—where methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days may reduce mortality 1. However, this applies to systemic corticosteroids, not inhaled formulations 1.

Inhaled Corticosteroids: Continue vs. Initiate

In Patients Already on ICS (COPD or Asthma)

Continue existing ICS therapy during acute pneumonia. The evidence shows:

• Prior ICS use is associated with lower incidence of parapneumonic effusion (5% vs 12%, OR 0.40) and more favorable pleural fluid chemistry 2
• ICS-treated patients demonstrate reduced systemic inflammatory markers (lower TNF-alpha and IL-6) on admission for CAP 3
• While ICS increases pneumonia risk in COPD patients (RR 1.59), this reflects chronic use patterns, not acute management decisions 4

For COPD exacerbations specifically, systemic corticosteroids (prednisone 30-40 mg daily for 5 days) are the standard of care and improve outcomes 5, 6. Continue maintenance ICS therapy alongside systemic steroids during the acute episode 5.

Do Not Initiate ICS for Pneumonia Treatment

There is no evidence supporting initiation of ICS as pneumonia therapy. The guideline recommendations against corticosteroids in CAP refer to systemic formulations 1, and inhaled delivery would provide inadequate systemic anti-inflammatory effect for severe pneumonia while potentially increasing local immunosuppression 7.

Critical Safety Considerations

Pneumonia Risk with Chronic ICS Use

• Fluticasone-containing ICS significantly increase pneumonia risk (RR 2.17 for severe pneumonia) 4
• Budesonide at medium and low doses does not significantly increase pneumonia risk 4, 8
• In asthma patients, fluticasone propionate carries a 7.92-fold increased risk of pneumonia hospitalization, while budesonide shows no significant association (IRR 1.23) 8

Practical Algorithm

For patients with asthma or COPD presenting with CAP:

1. Continue existing ICS at current dose—do not discontinue 5
2. Add systemic corticosteroids only if:
   • Severe CAP with septic shock refractory to fluids/vasopressors AND CRP >150 mg/L 1
   • COPD exacerbation component (prednisone 30-40 mg × 5 days) 5, 6
3. Do not initiate ICS if patient was not previously on them 1
4. Avoid systemic corticosteroids in influenza pneumonia (associated with increased mortality) 1

Common Pitfalls

• Do not withdraw ICS during acute illness—this increases exacerbation risk, particularly in patients with eosinophils ≥300 cells/μL 5
• Do not confuse the pneumonia-risk data (which reflects chronic ICS exposure) with acute management decisions—stopping ICS during pneumonia offers no benefit and may worsen underlying airway disease 2, 3
• Ensure pneumococcal and influenza vaccination in all COPD/asthma patients on chronic ICS to mitigate infection risk 7