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Vineet Chopra, MD; Scott A. Flanders, MD
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From the Department of Internal Medicine, Division of General Internal Medicine, University of Michigan Health System.

Correspondence to: Vineet Chopra, MD, 3119 Taubman Health Center, 1500 E Medical Center Dr, SPC 5376, Ann Arbor, MI 48104; e-mail: vineetc@med.umich.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(5):1249-1250. doi:10.1378/chest.09-2980
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To the Editor:

We thank Drs Young and Hopkins for their letter regarding our article in CHEST (November 2009)1 on the potential impact of statin use on pneumonia outcomes. We concur that the “healthy-user” effect may not be the only explanation for the positive association between statins and pneumonia. However (as discussed in our review), the precise manner by which statins modulate pneumonia outcomes remains unclear. Though plausible theories exist, no randomized controlled trial has yet addressed this issue. We note that since the release of our article, however, a population-based, case-control study found that statin use was not associated with a decrease in pneumonia risk.2

At this controversial crossroad, we argue that the question we should be asking is how better to design studies to capture any effect (positive or negative) of statins on pneumonia. In their retrospective review, Thomsen et al3 found that mortality among statin users with pneumonia was lower than that of nonusers at 30- and 90-day intervals. In a prospective study, Chalmers et al4 reported that statins decreased 30-day mortality in their cohort of 1,007 patients (adjusted odds ratio, 0.46; 95% CI, 0.25-0.85; P < .01). In contrast, the recent study by Dublin et al3 reported that statin treatment did not decrease the risk for pneumonia; rather, if anything, there was a slight increase in pneumonia risk among statin users.

It is pertinent to recognize that observational studies reviewing this subject suffer from methodologic limitations and selection bias. Although metaanalyses of the existing data may shed some light on this issue, we believe it is time for well-designed, randomized controlled clinical trials of statin users with pneumonia. Forward-looking randomized studies are critical because adjustment for comorbidities using purely retrospective data sources (databases, medical records, surveys, or administrative records) lacks the clinical dimensions (eg, functional status, socioeconomic status, comorbidities, and physiologic data) necessary for confidence in study findings. It is important that such trials be powered (n ≥ 1,000) to adequately assess the impact of statins on pneumonia.2-4 Likewise, such studies should also measure and report important clinical outcomes, such as death and complications, at early and late intervals.

Based on the numerous theories and ongoing controversies that surround the effect of statins on pneumonia, it is our hope that randomized controlled trials will be undertaken in the near future to clarify the role of statins in acute illnesses. Without such convincing data, the effect of statins on pneumonia is likely to remain a subject of ongoing debate.

Chopra V, Flanders SA. Does statin use improve pneumonia outcomes? Chest. 2009;1365:1381-1388. [CrossRef] [PubMed]
 
Dublin S, Jackson ML, Nelson JC, Weiss NS, Larson EB, Jackson LA. Statin use and risk of community acquired pneumonia in older people: population based case-control study. BMJ. 2009;338:b2137. [CrossRef] [PubMed]
 
Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sørensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia: population-based cohort study of 29,900 patients. Arch Intern Med. 2008;16819:2081-2087. [CrossRef] [PubMed]
 
Chalmers JD, Singanayagam A, Murray MP, Hill AT. Prior statin use is associated with improved outcomes in community-acquired pneumonia. Am J Med. 2008;12111:1002-1007. [CrossRef] [PubMed]
 

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References

Chopra V, Flanders SA. Does statin use improve pneumonia outcomes? Chest. 2009;1365:1381-1388. [CrossRef] [PubMed]
 
Dublin S, Jackson ML, Nelson JC, Weiss NS, Larson EB, Jackson LA. Statin use and risk of community acquired pneumonia in older people: population based case-control study. BMJ. 2009;338:b2137. [CrossRef] [PubMed]
 
Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sørensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia: population-based cohort study of 29,900 patients. Arch Intern Med. 2008;16819:2081-2087. [CrossRef] [PubMed]
 
Chalmers JD, Singanayagam A, Murray MP, Hill AT. Prior statin use is associated with improved outcomes in community-acquired pneumonia. Am J Med. 2008;12111:1002-1007. [CrossRef] [PubMed]
 
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