Systemic Glucocorticoids in COPD
Abstract & Commentary
Synopsis: A 10-day course of steroid treatment is more efficacious than a 3-day course in improving outcomes but does not reduce relapse rates.
Source: Sayiner A, et al. Chest. 2001;119:726-730.
The optimal duration of steroid treatment in the management of acute chronic obstructive pulmonary disease (COPD) exacerbations is not well defined, although they are used widely in clinical practice. Sayiner and colleagues conducted a randomized, single-blind, prospective study at a tertiary care center in Turkey to compare the efficacy of 3 days vs. 10 days of prednisone. A total of 198 patients were screened for the study, of which 36 patients met the inclusion criteria. Inclusion criteria were smoking history > 20 pack-years, severe airway obstruction with FEV1 < 35% of predicted, and severity of illness warranting hospitalization for the exacerbation. Patients with a personal or family history of asthma, atopy, allergic disease, or use of steroids within the last month were excluded. Patients who met the criteria were randomly assigned into one of two groups. Group 1 received prednisone 0.5 mg/kg q6h for 3 days and normal saline for the next 7 days as a placebo. Group 2 received prednisone 0.5 mg/kg q6h for 3 days and was then tapered rapidly over the next 7 days. Patients were given high-dose inhaled b-2 agonists, ipratropium bromide, theophylline, and antibiotics when indicated. Primary end points included FEV1 and PaO2 at 3 days and 10 days. Symptom score, adverse events, and recurrent exacerbation within 6 months were secondary end points.
There was no significant difference between the groups with respect to duration of COPD, smoking history, baseline FEV1, and PaO2. Both groups showed improvement in FEV1 and PaO2 level, but there was a more marked improvement in patients who received the 10-day course of prednisone. However, there was no significant difference between groups with respect to recurrent exacerbations.
Sayiner et al conclude that in severe COPD exacerbations, a 10-day course of steroid treatment is more effective than a 3-day course in improving the outcomes of PaO2 and FEV1, but the 10-day course has no benefit in terms of reducing the recurrence rate.
Comment by David Ost, MD, & Lingamurthy Ravi, MD
The optimum dose and duration of steroid treatment in the management of acute COPD exacerbation is not well defined. A study done by Albert and Martin in 1980 demonstrated that steroids given 4 times daily for 3 days produced an earlier increase in FEV1 relative to placebo treatment.1 This study did not include clinical outcomes. Another study by Niewoehner and Erbland compared systemic steroid therapy of 2 weeks vs. 8 weeks duration vs. placebo.2 Steroid treatment was associated with a significantly lower rate of treatment failure, decreased length of hospital stay, and more rapid improvement in FEV1. A final study by Davies and Angus showed similar results with a 2-week course of oral prednisone.3 In this study, they noted a more rapid improvement in FEV1 that reached a plateau in 5 days with little further change at 6 weeks.
This study by Sayiner et al provides useful information that adds to our understanding of the optimal duration of therapy. They compare a 3-day with a 10-day regimen of steroids. Among the 10-day group, the FEV1 improved at day 3 and continued to improve further to day 10. In contrast, among the 3-day group, the FEV1 improved to day 3, with no subsequent improvement at day 10. Based on the limited available evidence, the optimal duration of therapy for acute exacerbations of COPD is probably in the range of 5 to 14 days. (Dr. Ravi is a Resident, Department of Medicine, Nassau County Medical Center, Stony Brook, NY.)
References
1. Albert RK, Martin TR. Ann Intern Med. 1980;92: 753-758.
2. Niewoehner DE, Erbland ML. N Engl J Med. 1999; 340:1941-1947.
3. Davis L, Angus RM. Lancet. 1999;354:456-460.
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