Systemic Steroids in COPD Exacerbation
ABSTRACT & COMMENTARY
Source: Niewoehner DE, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1999;340:1941-1947.
While systemic corticosteroids have clearly been shown to be efficacious for acute asthma exacerbations, the role of corticosteroids is less certain for acute chronic obstructive pulmonary disease (COPD) exacerbations. This Veterans Affairs cooperative study examined hospitalized patients with COPD exacerbations who were at least 50 years of age, had a history of smoking, and had no other medical problems. Patients already taking systemic steroids upon admission were not eligible. Within 12 hours of ED presentation, subjects were randomized to receive either two weeks of corticosteroids (methylprednisolone 125 mg 4 times a day for 3 days, then tapering off from 60 mg daily over 2 weeks), eight weeks of corticosteroids (methylprednisolone 125 mg 4 times a day, then prednisone tapering off from 60 mg daily over 8 weeks), or placebo. All subjects received antibiotics and inhaled b2-agonists, ipratropium bromide, and triamcinolone. Treatment failure was defined as need for mechanical intubation, readmission for COPD, intensification of COPD therapy, or death.
Over two years, 271 subjects were enrolled. Treatment failure was significantly less in the two steroid groups than in the placebo group at 30 days (23% vs 33%) and at 90 days (37% vs 48%). The failure rate at six months did not differ between groups. There were no differences in failure rate between the two-week and eight-week regimen groups. Steroid-treated patients had a shorter hospital stay than placebo-treated patients (8.5 vs 9.7 days), although the study protocol required at least a three-day hospitalization. Fifteen percent of subjects receiving steroids required therapy for hyperglycemia, compared to 4% of subjects receiving placebo. Niewoehner and colleagues conclude that steroid therapy is of moderate benefit among patients hospitalized for COPD exacerbation.
Comment by David J. Karras, MD, FAAEM, FACEP
Much of our current bias toward using steroids for COPD therapy in the ED is an extrapolation of the compelling evidence that steroids benefit patients with asthma exacerbations.1 In actuality, the role of systemic corticosteroids for management of COPD exacerbation is not as clearly defined. Some studies have found no short-term benefit from steroid therapy for COPD exacerbation,2 while others have found steroids to be of modest benefit.3,4 All the studies have been relatively small. A meta-analysis of patients with stable COPD showed some benefit from steroid therapy.5
Although corticosteroids do not promptly benefit patients with acute COPD exacerbations, studies such as this large trial do show a longer-term advantage to systemic steroid administration. It is therefore reasonable to start such therapy in the ED for patients with moderate-to-severe COPD exacerbation, with important caveats. Niewoehner et al administered steroids only to hospitalized patients, who were presumably sicker than the larger population of COPD patients in the ED. The high incidence of medication-related hyperglycemia is cause for concern. The safety of fast-taper or no-taper steroid dosing (typically used for asthma exacerbations) is not addressed and should not be assumed. Anticholinergic and steroid inhalers, used by all patients in this study, have far fewer side-effects than systemic steroids and should be considered standard-of-care for management of COPD exacerbations.
References
1. Rowe BH, et al. Effectiveness of steroid therapy in acute exacerbations of asthma: A meta-analysis. Am J Emerg Med 1992;10:301-310.
2. Emerman CL, et al. Randomized controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of COPD. Chest 1989;95:563-567.
3. Thompson WH, et al. Controlled trial of prednisone in outpatients with acute COPD exacerbation. Am J Respir Crit Care Med 1996;154:407-412.
4. Albert RK, et al. Controlled clinical trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency. Ann Intern Med 1980;92:753-758.
5. Callahan CM, et al. Oral corticosteroid therapy for patients with stable COPD: A meta-analysis. Ann Intern Med 1991;114:216-223.
Which of the following is true regarding the management of COPD exacerbations?
a. Oral corticosteroids are rarely, if ever, indicated.
b. Oral corticosteroid therapy obviates the need for anticholinergic therapy.
c. There are no significant side-effects to a two-week course of steroid therapy.
d. Oral plus inhaled steroid therapy is more effective than inhaled steroid therapy alone.
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