Steroids for COPD: Less Is Probably More
A 2010 observational study suggested that relatively low-dose oral corticosteroids were as good as — or better than — high-dose parenteral steroids in hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations, but intensive care unit (ICU) patients were excluded from that study (NEJM JW Gen Med Jun 24 2010) [Link to free full-text JAMA article PDF]. Whether these results can be extrapolated to patients admitted to ICUs is unclear.
Researchers evaluated 17,239 patients (77% older than 60; 31% tobacco users) with COPD exacerbations who were admitted to ICUs at 473 U.S. hospitals. Nearly one third of patients received noninvasive ventilation; 15% were intubated. Almost all patients received antibiotics and bronchodilators. Methylprednisolone doses were categorized as either high (>240 mg) or low (≤240 mg), based on total methylprednisolone administered on hospital day 1 or 2; 11,083 patients (64%) received high doses.
Patients in the two groups were matched by propensity scoring. After adjusting for unbalanced covariates, the groups had similar in-hospital mortality. Compared with high-dose treatment, low-dose treatment was associated with shorter ICU and hospital lengths of stay, lower hospital costs, and shorter duration of mechanical ventilation. Low-dose patients were less likely to require insulin therapy or develop fungal infections.
This study strongly suggests that a moderate dose of steroids is more than adequate to treat ICU patients with severe COPD exacerbations. I would feel comfortable treating such patients with <240 mg of methylprednisolone (i.e., 80 mg to 160 mg), but a randomized trial is necessary to determine optimal dosing and duration of steroids.
Patricia Anne Kritek, MD, EdM reviewing Kiser TH et al. Am J Respir Crit Care Med 2014 May 1. Abroug F and Krishnan JA. Am J Respir Crit Care Med 2014 May 1.
Kiser TH et al. 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; 189:1052.