Low-Dose Corticosteroids Better for Acute Exacerbations of COPD

A recent study found that two-thirds of patients admitted to intensive care units (ICUs) across the United States with an acute exacerbation of chronic obstructive pulmonary disease (COPD) receive high-dose corticosteroid therapy, and higher doses of corticosteroids are associated with worsened clinical outcomes and increased steroid-related adverse events.

“The results of our study suggest that higher doses of systemic corticosteroids are not better in critically ill patients with acute exacerbations of COPD,” said lead author Tyree H. Kiser, PharmD, FCCM, FCCP, BCPS, Associate Professor, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, Colorado. “This is important because critically ill patients have increased hospital length of stay, mortality, and costs associated with their hospital admissions.”
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There is a lack of prior research on corticosteroid dosing in individuals with acute exacerbation of COPD who are admitted directly to the ICU. Further, there are no studies assessing the effect of different corticosteroid dosing regimens on mortality.

“Our study question originated during patient care rounds in the medical ICU at the University of Colorado Hospital,” Kiser explained to Consultant360. “[Coauthor] Dr. R. William Vandivier and I were discussing the benefits and risks of corticosteroids in one of our ICU patients with an acute exacerbation of COPD and the lack of data to guide corticosteroid dosage in our practice. We made it our quest to try to find an optimal corticosteroid treatment regimen for critically ill patients.”

He pointed out that critically ill individuals with acute exacerbations of COPD have mortality rates that are 10 to 15 times higher than those of non-critically ill hospitalized patients, so finding interventions that improve outcomes in these patients is vital.

To assess the safety and effectiveness of different corticosteroid doses in patients admitted to the ICU with an acute exacerbation of COPD, researchers conducted a pharmacoepidemiologic cohort study involving 17,239 individuals. Participants were admitted to 473 hospitals between 2003 and 2008 and were divided into two groups: those who were treated with lower-dose corticosteroids (methylprednisolone ≤240 mg/day; n=6156) or high-dose corticosteroids (methylprednisolone >240 mg/day; n=11,083) during hospital Day 1 or 2.

Kiser and colleagues found that lower-dose corticosteroid therapy was associated with reduced hospital and ICU lengths of stay, hospital costs, length of invasive ventilation, need for insulin therapy, and fungal infections after propensity score matching and adjustments. Lower-dose corticosteroid therapy was not, however, linked to a significant reduction in mortality.

“We were surprised that the data were consistent regardless of exacerbation severity,” said Kiser. “Lower dose corticosteroids demonstrated trends toward benefit in all patients, even those requiring ventilator support.”

According to Kiser, the main limitation of their study is its observational design. 

“Our study evaluated patients in a real world environment rather than a prospective controlled clinical trial,” he said. “Therefore, we can only identify associations between corticosteroid treatment and outcomes.”

He stated that, “Similar to studies in non-critically ill patients with acute exacerbations of COPD, more steroids are not better. Although our study does not provide the optimal dose and duration of steroids in critically ill patients, it does provide clinicians with evidence that can guide them toward utilizing lower dosing strategies.”

Kiser pointed out that a clinical trial is needed to confirm these study findings.

“If the results of our study are confirmed and implemented, changing current practice patterns to utilize lower dose corticosteroids would result in substantial reductions in healthcare expenditures and steroid-related adverse events,” he said.  

This study appeared in the American Journal of Respiratory and Critical Care Medicine.

-Meredith Edwards White

Reference

Kiser TH, Allen RR, Valuck RJ, Moss M, Vandivier RW. Outcomes associated with corticosteroid dosage in critically ill patients with acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2014 May 1;189(9):1052-64. doi: 10.1164/rccm.201401-0058OC.