Thursday, January 15, 2015

When is it Indicated to Start Corticosteroids in COPD Exacerbations?

Rationale:
  • Studies concluded that systemic (oral or intravenous) glucocorticoids reduced treatment failure
  • increased the rate of improvement in lung function and symptoms
  • more rapid increase in FEV1, fewer withdrawals, and a significantly shorter hospital stay
  • benefits of glucocorticoids appear to be greatest in the first 72 hours after administration

Outpatient exacerbations:
  • small, but significant clinical effect
  • Patients who received prednisone (40mg for 10 days) were less likely to return with increasing dyspnea within 30 days (27 versus 43 percent). In addition to a lower rate of relapse, prednisone therapy was associated with decreased dyspnea
Hospitalised Patients:
  • Rate of treatment failure was about 10 percent lower
  • Shorter hospital stay and more rapid improvement of FEV1
  • No difference between efficacy of oral and IV
Adverse effect of short term therapy:
  • Only hyperglycemia was more common in the glucocorticoid-treated groups
  • Patients who received the eight-week course of glucocorticoids had a tendency to have more severe infections, particularly pneumonia
  • Patients treated with short-term, high-dose glucocorticoids for septic shock have a significantly increased risk of secondary bacterial infection and an increased mortality
Selection criteria:
  • Currently, no criteria have been established for deciding which patients benefit most from corticosteroid therapy.
  • Thus, all patients without serious contraindications should receive systemic corticosteroids for severe exacerbations of COPD


Severity of exacerbation
Description
Mild
Can be controlled with an increase in dosage of regular medications
Moderate
Requires treatment with systemic corticosteroids or antibiotics
Severe
Requires hospitalization or evaluation in the emergency department




Duration:
  • No more than two weeks of therapy are needed; shorter courses may achieve adequate outcomes but need further study.
  • Extending the duration of therapy beyond 2 weeks and using higher doses does not confer additional benefits, but can increase the risk of short-term side effects such as hyperglycemia and insomnia
  • If steroid therapy is continued for longer than 2 weeks, a tapering schedule should be employed to avoid hypothalamic-pituitary-adrenal axis suppression
  • As a rough guide, full dose therapy (eg, prednisone 40 mg daily) is given for 5 to 14 days
Treatment:
  • a compromise approach to dosing; administer one or more high doses (eg, methylprednisolone 80 to 125 mg) in the first 24 hours with rapid conversion to lower-dose therapy (prednisone 40 to 60 mg per day) if the patient is improving.
  • IV glucocorticoids are typically administered to patients who present with a severe exacerbation, who respond poorly to oral glucocorticoids, unable to take oral medication, or who may have impaired absorption due to decreased splanchnic perfusion (eg, patients in shock).
  •  A reasonable alternative is to use a regimen of prednisone or its equivalent in doses of 30 to 60 mg per day for the duration of therapy

futher reading:

References:
  1. http://www.aafp.org/afp/2010/0301/p607.html
  2. http://respiratory-research.com/content/15/1/38
  3. http://www.patient.co.uk/doctor/acute-exacerbations-of-copd
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2111219/
  5. www.uptodate.com

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