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Three Part Question

In [patients with an acute exacerbation of COPD] are [steroids prior to discharge better than no steroids] at [improving outcome and hastening recovery]?

Clinical Scenario

A 55yr old man, known to have COPD comes to casulty more short of breath than usual and with a history of recently coughing purulent sputum. You treat him in the ED with continuous nebulised bronchodilater therapy, oral steroids as well as antibiotics. He starts to improve and on reasessing him clinically, after reviewing his chest X Ray and blood tests you decide to discharge him with community follow up. You wonder whether he should also be started on course of steroids in addition to his antibiotics.

Search Strategy

COCHRANE LIBRARY Issue 4 2005
Ovid MEDLINE 1966-November 2005
Embase 1980–2005 Week 47
Medline:[{COPD.mp. or exp Pulmonary Disease, Chronic Obstructive or COAD.mp. or chronic bronchitis.mp. or exp Bronchitis, Chronic OR emphysema.mp. or exp EMPHYSEMA/ or exp PULMONARY EMPHYSEMA} AND [{acute.mp. or exp ACUTE DISEASE or exacerbation.mp}] AND [{exp STEROIDS/ or steroids.mp or steroid$.mp or hydrocortisone.mp. or exp HYDROCORTISONE or hydrocort$.mp. or exp Prednisone/ or exp Prednisolone/ or predniso$.mp or glucocorticoid$.mp or exp GLUCOCORTICOIDS}] LIMIT to Human and English language
Embase:[{COPD.mp. or COAD.mp. or exp Chronic Obstructive Lung Disease/ or chronic bronchitis.mp. or exp Chronic Bronchitis/ or exp Lung Emphysema/ or exp Emphysema} AND {exp Acute Disease/ or acute.mp. or exacebation.mp.} AND { exp Hydrocortisone/ or hydrocort$.mp. or exp Prednisolone/ or predniso$.mp.} Limit to Human, English language and Clinical Queries "treatment high sensitivity"

Search Outcome

237 papers found of which one was a recently updated well done systematic review found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wood-Baker RR et al 2005 Tasmania	All randomised controlled trials comparing oral or parenteral corticosteroids with a placebo in the treatment of acute exacerbations of COPD A total of 921 participants were included in the nine studies contributing to the meta-analysis	Systematic Review	Treatment Failure ie Relapse/Return to ED, Re-admission rates	7 studies; 805 patients; Steroids reduced the risk treatment failure: odds ratio 0.48; 95% CI 0.34 to 0.68. NNT 9.	The studies were not designed to look at mortality and therefore the follow up was not for a long period of time. The primary outcome was relapse rates and re-admission rates and mortality was secondary outcome measure.
			Death	9 studies; 910 patients; no statistically significant difference, Odds Ratio 0.85; 95% CI 0.45 to 1.59.
			FEV1 upto 72 hours	7 studies;652 patients; weighted mean difference 140; 95% CI 80 to 200 ml
			Arterial blood gas measurements (ABG	2 studies 155 patients; improvements in pO2 at 72 hrs; Standardised Mean Difference 0.35 [0.03, 0.67]
			Dyspnoea scores	2 studies showed diff at 72 hrs; 1 no diff. no data from remaining studies
			Adverse drug effects (ADE)	7 studies; 650 patients;odds ratio 2.29; 95% confidence interval 1.55 to 3.38. Overall one extra adverse effect occured for every 6 people treated (95% CI 4 to 10). The risk of hyperglycaemia was significantly increased, odds ratio 5.48; 95% confidence interval 1.58 to 18.96.
			Adverse effect- hyperglycaemia	3 studies; 313 patients; odds Ratio 5.48 [1.58, 18.96]
			Late FEV1 (litres)	5 studies; 537 patinets;Weighted Mean Difference 0.03 [-0.04, 0.10]

Comment(s)

Treatment of patients with acute exacerbations of COPD with corticosteroids is a common practice. The evidence shows that this significantly improves lung function and breathlessness up to the first 72 hours. It also reduces the treatment failure within the first 30 days. However, these effects appear to be short lived and there is no effect on mortality. Also there is an increased incidence of adverse effects related to steroids. However, the studies were not designed to look at long term mortality outcomes and this seems reasonable as the intervention was a short course of steroids and hence the effects were observed for a maximum period of 30 days.

Clinical Bottom Line

The use of steroids has clear benefit in the acute management of the patient but with added risk of adverse drug effects and with no clear long term benefit in improvement in lung function or increased life expectancy

Level of Evidence

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

References

1. Wood-Baker RR, Gibson PG, Hannay M. et al. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease The Cochrane Database of Systematic Reviews 2005 Issue 1 Art. No.: CD001288. DOI: 10.1002/14651858