Systemic Corticosteroids for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

A Cochrane review [Abstract] 1 included 16 studies comparing systemic corticosteroid with placebo, with a total of 1787 subjects. 13 studies contributed data to the analyses (n = 1 620). Systemic corticosteroids significantly reduced the risk of treatment failure compared with placebo (OR 0.48, 95% CI 0.35 to 0.67; 9 studies, n = 917, median treatment duration 14 days; NNT = 9, 95% CI 7 to 14). The rate of relapse by one month was lower in patients treated with systemic corticosteroids (HR 0.78; 95% CI 0.63 to 0.97, 2 studies, n = 415). Mortality up to 30 days was not reduced by treatment with systemic corticosteroid (OR 1.00; 95% CI 0.60 to 1.66; 12 studies, n = 1 319). FEV₁, measured up to 72 hours, showed significant treatment benefits (mean difference [MD] 140 ml; 95% CI 90 to 200; 7 studies; n = 649); however, this benefit was not observed at later time points. The likelihood of adverse events increased with corticosteroid treatment (OR 2.33; 95% CI 1.59 to 3.43; NNH for one extra adverse effect = 6, 95% CI 4 to 10). The risk of hyperglycaemia was significantly increased (OR 2.79; 95% CI 1.86 to 4.19). For general inpatient treatment, duration of hospitalisation was significantly shorter with corticosteroid treatment (MD -1.22 days; 95% CI -2.26 to -0.18; 4 studies, n=480), with no difference in length of stay the intensive care unit (ICU) setting. Comparison of parenteral versus oral treatment showed no significant difference in the primary outcomes of treatment failure, relapse or mortality or for any secondary outcomes (3 studies, n= 239).

Another Cochrane review [Abstract] 1 comparing the efficacy of shorter (≤ 7 days) and longer (> 7 days) duration systemic corticosteroid treatment in acute COPD exacerbations included 8 studies with a total of 582 participants (mean ages from 65 to 73 years). Short course treatment varied between 3 and 7 days and longer duration 10 to 15 days. Oral prednisolone was used in 5 studies and intravenous corticosteroid treatment in 2 studies. There was no significant difference between shorter and longer treatment duration in the risk of treatment failure (OR 0.72, 95% CI 0.36 to 1.46; 4 studies, n=457), in risk of relapse (a new event) (OR 1.04, 95% CI 0.70 to 1.56; 4 studies, n=478), in length of hospital stay (MD -0.61 days, 95% CI -1.51 to 0.28; 3 studies, n=421), in lung function at the end of treatment (MD FEV₁ -0.04 L, 95% CI -0.19 to 0.10, I² =58%; 4 studies, n=187), nor in the likelihood of an adverse event (OR 0.89, 95% CI 0.46 to 1.69; 5 studies, n=503). Time to the next COPD exacerbation did not differ in one large study that was powered to detect non-inferiority and compared 5 days versus 14 days of systemic corticosteroid treatment over 6 months of follow-up (HR 0.95, 95% CI 0.66 to 1.37; 1 study, n=311).

References

• Walters JA, Tan DJ, White CJ et al. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014;(9):CD001288. [PubMed]
• Walters JA, Tan DJ, White CJ et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014;(12):CD006897. [PubMed]