Topic: Effect of systemic glucocorticoids on exacerbations of COPD

Appraiser: R. Watkins Date Appraised: October 22, 1999

65 yo ww with pmh of severe COPD with recent spirometry showing an FEV1 of .66L and and FEV1/FVC of 35 % who presents and is hospitalized secondary to a COPD exacerbation. She is hypoxic and has a normal CXR. She is on 2L NC oxygen at home. She reports a cough and worsening SOB in the 3 days prior to presentation. She receives Solu-Medrol 125 mg in the ED prior to being admitted. The medicine team questions the efficacy of steroids in COPD exacerbations .

Clinical Bottom Lines:

  1. Withholding steroids* from 9 people presenting with severe COPD requiring admission to the hospital over a two week period and while giving antibiotics for 1 week as well as inhaled Agonists and Atrovent will result in one treatment failure** within 30 days of admission.
  2. When followed for 6 months the treatment failure rates between placebo and glucocorticoid therapy were not statistically significant.
  3. Withholding steroids* from 7 people presenting with severe COPD exacerbation requiring admission to hospital over a 2 week period will prevent one episode of hyperglycemia requiring treatment.

*IV Solu-Medrol 125mg Q 6 h X 72 h, then oral prednisone (60mg on days 4-7, 40 mg on days 8-11, and 20 mgs on days 12-15)

**defined as death, intubation, readmission for COPD or intensification of therapy

The Evidence: RDBCT to assess the equivalence of systemic glucocorticoids given for two or eight weeks vs placebo in the treatment of hospitalized patients with COPD exacerbation. The withholding of steroids was viewed as an experimental intervention associated with no glucocorticoid related complications.

Treatment assignment
#(%)

   

placebo   

glucocorticoids   

pvalue   

ARI

NNH

   

(N=111)   

2 weeks

 8 weeks 

2wks

 8wks   

2wks 

 8wks

outcome   

   

(N=80)

 (N=80)

treatment failure

30 days   

37(33)   

19(24)

 18(22)

0.04  

9

 11

11

 9

60 days   

53(48)   

30(38)

 29(36)

0.04

10

 12

10

 8

182 days   

60(54)   

39(49)

 42(52)

0.58

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Comments:

True effects of withholding steroids* unclear since over 50% of placebo group at some point received systemic steroids at some point.

Study population included people with severe copd FEV1 of less than or equal to 1.5 L and can we extrapolate to individuals with less severe disease?

Source: Niewoehner , Dennis E et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. NEJM 1999;340:1941-1946.