• 
• 

Three Part Question

In [patients with an acute exacerbation of COPD] are [intravenous or oral steroids] better at [reducing length of hospital admission and mortality]

Clinical Scenario

A 73yr old man with COPD is seen in the Emergency Department. You give him salbutamol and atrovent nebulisers but he remains breathless. You wonder whether giving intravenous or oral steroids would reduce length of hospital stay and his risk of death.

Search Strategy

EMBASE from 1980 to 2011 Week 08, Ovid MEDLINE 1948 to Feb Week 4 2011 with the following search strategy

((COPD OR coad).af OR (‘chronic obstructive’ adj3 disease).af) AND (steroid.af) AND (intravenous.af OR oral.af) AND ((acute OR emergen$ OR urgen$ OR decompensat$ OR sudden).af)

Search Outcome

One-hundred and seventy-four papers were found, of which two were considered relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
de Jong et al, 2007, Netherlands	210 patients over 40 years old with a >10 pack year history of smoking and evidence of airflow limitation defined as FEV1/FVC ratio <70% and FEV1<80% of predicted	Randomised, controlled double-blind study	Treatment failure (death, admission to ICU, readmission to hospital or need to intensify pharmacological treatment)	Treatment failure was 61.7% for the intravenous group vs 56.3% for the oral group (95% CI lower bound −5.8%)	Single centre trial The value should be negative or minus 5.8% as the lower bound of the 95% confidence interval.
			Length of stay	11.9 days±8.6 days for the intravenous group vs 11.2 days±6.7 days for the oral group
			Mortality	Five patients died in the intravenous group vs two patients in the oral group
Lindenaeuer et al, 2010, USA	79 985 patients over 40 years with a diagnosis of COPD admitted to 414 hospitals that provide information to a database. Excluded patients admitted directly to ITU	A pharmacoepidemiological cohort study with multivariable adjustment	Risk of treatment failure in propensity-matched comparison of patients receiving oral versus intravenous steroids	OR 0.93; 95% CI 0.84 to 1.02	Retrospective cohort study. Used statistical methods to compensate for potential confounding factors such as increased use of intravenous therapy in sicker patients
			Length of stay in adjusted model comparing oral and intravenous groups	Ratio 0.92; 95% CI 0.91 to 0.94

Comment(s)

Although the use of steroids for the treatment of acute exacerbations of chronic obstructive airways disease is well supported by the available literature, the optimal dose, length of treatment and method of administration are not yet established, Walters et al. There are few data comparing oral versus intravenous administration of steroids, but the data available do not demonstrate any inferiority in efficacy for the oral form. Given the significant risk of adverse events associated with steroid use, the minimal effective dose for the least amount of time would be preferable.

Editor Comment

COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in one second; FVC, forced vital capacity; ICU, intensive care unit; ITU, intensive treatment unit.

Clinical Bottom Line

In line with NICE guidelines, oral steroids should be given to patients with acute exacerbations of COPD in the absence of any contraindications.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. de Jong YP, Uil SM, Grotjohan HP et al. Oral or IV Prednisolone in the Treatment of COPD Exacerbations. A Randomized, Controlled, Double-blind Study. Chest 2007 132 ; 1741-1747.
2. Lindenauer PK, Pekow PS, Lahti MC, et al. Association of Corticosteroid Dose and Route of Administration With Risk of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease J Am Med Assoc 2010;303:2359–67.
3. Walters JAE, Gibson PG, Wood-Baker R, et al. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2009 (1): CD001288. doi:10.1002/14651858.CD001288.pub3.
4. National Clinical Guideline Centre. Chronic Obstructive Pulmonary Disease: Management Of Chronic Obstructive Pulmonary Disease In Adults. London: National Clinical Guideline Centre, 2010. 2010. http://guidance.nice.org.uk/CG101/Guidance/pdf/English.