Differential association of fluticasone furoate and budesonide with clinically detected COVID-19: a retrospective cohort study
et al., BMJ Open Respiratory Research, doi:10.1136/bmjresp-2025-003800, Apr 2026
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Retrospective 334 outpatients (102 ICS users, 232 non-ICS users) over 4 years at a single Japanese center, showing lower COVID-19 cases with fluticasone furoate compared to budesonide, and lower cases for ICS users vs. non-ICS users.
Tsunemi et al., 1 Apr 2026, retrospective, Japan, peer-reviewed, 8 authors, study period July 2020 - July 2024.
Contact: tsunemi7777@gmail.com.
Abstract: To cite: Tsunemi M, Kuribayashi K, Ishimura E, et al . Differential association of fluticasone furoate and budesonide with clinically detected COVID- 19: a retrospective cohort study. BMJ Open Respir Res 2026; 13 :e003800. doi:10.1136/ bmjresp-2025-003800
- Additional supplemental material is published online only. To view, please visit the journal online (https:// doi. org/ 10. 1136/ bmjresp- 2025003800).
Received 8 October 2025 Accepted 4 March 2026
© Author(s) (or their employer(s)) 2026. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ Group.
1 Tsurumi Medical Center, Osaka, Japan 2 Department of Respiratory Medicine and Hematology, Hyogo Medical University, Nishinomiya, Japan 3 Meijibashi Hospital, Matsubara, Japan 4 Sennansinge Clinic, Osaka, Japan 5 Tokyo Tower View Clinic Azabujuban, Tokyo, Japan 6 Shuutetsukai MUTO CLINIC, Tokyo, Japan
Correspondence to
Dr Masaki Tsunemi; tsunemi7777@ gmail. com
Differential association of fluticasone furoate and budesonide with clinically detected COVID- 19: a retrospective cohort study
Masaki Tsunemi , 1 Kozo Kuribayashi , 2 Eiji Ishimura, 3 Kiyokazu Yoshinoya , 4 Tetsuya Hayashi, 5 Toru Muto, 6 Hiroyuki Sakamoto, Takashi Kijima 2
ABSTRACT
Objectives To assess whether fluticasone furoate (FF) use, compared with budesonide (BUD), is associated with fewer clinically detected COVID- 19 events among inhaled corticosteroids (ICS) users, and to explore virus- specificity using influenza as a comparator outcome. We hypothesised that FF may provide strong local anti- inflammatory effects with limited systemic immunosuppression.
Design Retrospective cohort with outpatient follow- up over 4 years.
Setting Single Japanese medical centre.
Participants 334 adults (102 ICS users; 232 non- ICS) followed from July 2020 to July 2024.
Main outcome measures Clinically detected COVID- 19 (primary) and influenza (secondary). The primary exposure comparison was FF versus BUD among ICS users; ICS versus non- ICS was analysed secondarily (exploratory). Cox proportional hazards and logistic regression are adjusted for demographics, comorbidities, vaccination and systemic corticosteroids.
Results Seventy- nine COVID- 19 and 14 influenza events occurred. Among ICS users, FF was associated with fewer clinically detected COVID- 19 events than BUD (adjusted HR 0.12, 95% CI 0.02 to 0.73; crude 6.5% vs 32.3%; Fisher's exact p=0.0047). Under symptom- based testing, ICS users also had fewer clinically detected COVID- 19 events than non- ICS users (adjusted HR 0.46, 95% CI 0.22 to 0.94), although this comparison is limited by baseline imbalance and should be interpreted as exploratory and non- causal. Conclusions Under symptom- triggered testing, FF was associated with fewer clinically detected COVID- 19 events than BUD in the head- to- head comparison among ICS users. The ICS versus non- ICS comparison is exploratory due to confounding by indication and structural imbalance. These findings are hypothesis- generating and warrant prospective studies with systematic testing and stronger designs.
DOI record:
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"abstract": "<jats:sec>\n <jats:title>Objectives</jats:title>\n <jats:p>To assess whether fluticasone furoate (FF) use, compared with budesonide (BUD), is associated with fewer clinically detected COVID-19 events among inhaled corticosteroids (ICS) users, and to explore virus-specificity using influenza as a comparator outcome. We hypothesised that FF may provide strong local anti-inflammatory effects with limited systemic immunosuppression.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Design</jats:title>\n <jats:p>Retrospective cohort with outpatient follow-up over 4 years.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Setting</jats:title>\n <jats:p>Single Japanese medical centre.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Participants</jats:title>\n <jats:p>334 adults (102 ICS users; 232 non-ICS) followed from July 2020 to July 2024.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Main outcome measures</jats:title>\n <jats:p>Clinically detected COVID-19 (primary) and influenza (secondary). The primary exposure comparison was FF versus BUD among ICS users; ICS versus non-ICS was analysed secondarily (exploratory). Cox proportional hazards and logistic regression are adjusted for demographics, comorbidities, vaccination and systemic corticosteroids.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Results</jats:title>\n <jats:p>Seventy-nine COVID-19 and 14 influenza events occurred. Among ICS users, FF was associated with fewer clinically detected COVID-19 events than BUD (adjusted HR 0.12, 95% CI 0.02 to 0.73; crude 6.5% vs 32.3%; Fisher’s exact p=0.0047). Under symptom-based testing, ICS users also had fewer clinically detected COVID-19 events than non-ICS users (adjusted HR 0.46, 95% CI 0.22 to 0.94), although this comparison is limited by baseline imbalance and should be interpreted as exploratory and non-causal.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Conclusions</jats:title>\n <jats:p>Under symptom-triggered testing, FF was associated with fewer clinically detected COVID-19 events than BUD in the head-to-head comparison among ICS users. The ICS versus non-ICS comparison is exploratory due to confounding by indication and structural imbalance. These findings are hypothesis-generating and warrant prospective studies with systematic testing and stronger designs.</jats:p>\n </jats:sec>",
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