Incidence of oral thrush in patients with COPD prescribed inhaled corticosteroids: Effect of drug, dose, and device

P.N. Richard Dekhuijzen, Maria Batsiou, Leif Bjermer, Sinthia Bosnic-Anticevich, Henry Chrystyn, Alberto Papi, Roberto Rodriguez-Roisin, Monica Fletcher, Lucy Wood, Alessandra Cifra, Joan B Soriano, David B. Price

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35 Citations (Scopus)
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Background and aims

Little information is available on real-life occurrence of oral thrush in COPD patients treated with ICS. We investigated oral thrush incidence in COPD patients prescribed FDC ICS/LABA therapies and assessed whether it is modulated by the ICS type, dose, and delivery device.


We conducted a historical, observational, matched cohort study (one baseline year before and one outcome year after initiation of therapy) using data from the UK Optimum Patient Care Research Database. We assessed oral thrush incidence in patients initiating long-acting bronchodilators or FDC ICS/LABA therapy. We then compared different combination therapies (budesonide/formoterol fumarate dihydrate [BUD/FOR] and fluticasone propionate/salmeterol xinafoate [FP/SAL]) and devices (DPI and pMDI).


Patients prescribed FDC ICS/LABA had significantly greater odds of experiencing oral thrush than those prescribed long-acting bronchodilators alone (adjusted OR 2.18 [95% CI 1.84–2.59]). Significantly fewer patients prescribed BUD/FOR DPI developed oral thrush compared with FP/SAL DPI (OR 0.77 [0.63–0.94]) when allowing for differences in prescribed doses between the drugs. A significantly smaller proportion of patients developed oral thrush in the FP/SAL pMDI arm than in the FP/SAL DPI arm (OR 0.67 [0.55–0.82]). Additionally, in the FP/SAL cohort (both DPI and pMDI), increased risk of oral thrush was significantly associated with high ICS daily dose (OR 1.97 [1.22–3.17] vs low daily dose).


ICS use increases oral thrush incidence in COPD and this effect is dose-dependent for FP/SAL therapies. Of the therapies assessed, FP/SAL pMDI and BUD/FOR DPI may be more protective against oral thrush.
Original languageEnglish
Pages (from-to)54-63
Number of pages10
JournalRespiratory Medicine
Early online date22 Sept 2016
Publication statusPublished - Nov 2016

Bibliographical note

The authors wish to thank Derek Skinner for his assistance with data extraction and analysis. Rafael Mares and Bakhtiyor Khalikulov are particularly thanked for assistance with study design and data extraction during the preliminary phase of the study. This study was conducted by Research in Real Life Ltd, under a subcontract by Observational and Pragmatic Research Institute Pte Ltd, with institutional support from Teva Pharmaceuticals Europe B.V.


  • oral candidiasis
  • chronic obstructive pulmonary disease
  • inhaled corticosteroid
  • spacer
  • dry powder inhaler
  • pressurised metered-dose inhaler


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