Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

 

Abstract

Background

COPD is a common condition, mainly related to smoking. Acute exacerbations of COPD, usually related to superimposed infection, occur commonly and systemic corticosteroids are widely used in their management in combination with other treatments including antibiotics, oxygen supplementation and bronchodilators.

Objectives

To determine the efficacy of corticosteroids, administered either parenterally or orally, on the outcomes of acute exacerbations of COPD.

Search methods

Searches were carried out using the Cochrane Airways Group COPD RCT register with additional studies sought in the bibliographies of randomised controlled trials and review articles. Authors of identified randomised controlled trials were contacted for other published and unpublished studies. The last search was carried out in August 2008.

Selection criteria

Randomised controlled trials comparing corticosteroids, administered either parenterally or orally, with appropriate placebo control. Other interventions e.g. bronchodilators and antibiotics were standardised. Clinical studies of acute asthma were excluded.

Data collection and analysis

Data were extracted independently by two reviewers. Data measured but not reported were sought from authors of included studies. Trials were combined using Review Manager for analyses.

Main results

Eleven studies (n=1081) fulfilled the inclusion criteria and 10 studies contributed data for analyses (n=1051). There were significantly fewer treatment failures within thirty days in patients given corticosteroid treatment, Odds Ratio (OR) 0.50; 95% confidence interval (CI) 0.36 to 0.69 and Hazard Ratio 0.78; 95% CI 0.63 to 0.97. It would have been necessary to treat 10 patients (95%CI 7 to 16) with corticosteroids to avoid one treatment failure in this time period. Duration of hospitalisation was significantly shorter with corticosteroid treatment, mean difference -1.22 days; 95% CI -2.26 to -0.18. For FEV1 there were significant treatment benefits with mean differences at the early time point (to 72 hours), 140 ml; 95% CI 90 to 190 ml and at end of treatment (up to 15 days) 80 ml; 95% confidence interval 10 to 160. There was a significant improvement in breathlessness and blood gases at both time points. There was no significant effect on mortality but an increased likelihood of an adverse event associated with corticosteroid treatment, OR 2.33; 95% CI 1.60 to 3.40. Overall one extra adverse effect occurred for every 5 people treated (95% CI 4 to 9). The risk of hyperglycaemia was significantly increased, OR 4.95; 95% CI 2.47 to 9.91.

Authors' conclusions

Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment and shortens hospital stay. It increases the rate of improvement in lung function and dyspnoea and the improvement continues during treatment, but there is a significantly increase in the risk of an adverse drug event occurring. The optimal dose and length of treatment regime needs to be better defined.

 

Plain language summary

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

People with Chronic Obstructive Pulmonary Disease (COPD), sometimes called emphysema or chronic (obstructive) bronchitis, have episodes of deterioration which may need a hospital stay. Such exacerbations are often caused by infections. Treatment with corticosteroids, such as prednisolone, prednisone or cortisone, has become common. This review found that corticosteroids help improve symptom such as breathlessness, improve lung function, shorten hospital stays and reduce the need to seek extra medical attention. There are some short lived side effects. The optimal corticosteroid regime has not been defined.

 

摘要

背景

全身性皮質類固醇對於治療慢性阻塞性肺病的急性惡化

慢性阻塞性肺病是一種與抽煙相關的常見的疾病。急性惡化常與感染有關。全身性皮質類固醇廣泛地使用並和抗生素，氧氣及支氣管擴張劑一同治療慢性阻塞性肺病的急性惡化。

目標

評估口服或注射的皮質類固醇對於治療慢性阻塞性肺病的急性惡化的療效。

搜尋策略

搜尋是使用 Cochrane Airways Group COPD RCT register。其外的資料也由隨機對照試驗以及評論性文章中的目錄中搜尋。 為了搜尋其他已發表及尚未被發表的研究，我們也聯絡了參與隨機對照試驗的作者們。最後的搜尋在2008年8月執行。

選擇標準

隨機對照臨床試驗比較皮質類固醇(口服或注射)與安慰劑。標準化其他處置如抗生素及支氣管擴張劑的治療。排除急性氣喘的臨床試驗。

資料收集與分析

資料是由兩位審閱者獨立完成。未發表的資料是由作者那取得。臨床試驗是用Review manager軟體來合併及分析。

主要結論

11個研究(n = 1081)符合分析條件，10個研究(n = 1051)提供資料做為分析。在接受皮質類固醇治療的30天內，治療失敗的例子顯著較少。勝算比(OR)0.50；95%信賴區間(CI)0.36∼0.69；危險比0.78；95%CI是0.63∼0.97。在這段時間，以皮質類固醇治療10個病人(95%CI 7∼16)，可以避免1個治療失敗病人發生。以皮質類固醇治療顯著縮短住院時間，平均差異−1.22天；95%CI −2.26∼0.18。對FEV1而言，以皮質類固醇治療在早期(72小時)能達到顯著益處，140ml；95%CI 90∼190ml。在治療結束(∼15天) 80ml；95%CI 10∼160。皮質類固醇治療無論在早期或晚期均可顯著改善呼吸困難以及血液氣體檢驗 (blood gas)。皮質類固醇治療對死亡率無顯著功效，但會增加藥物不良事件；OR 2.33；95%CI 1.60∼3.40。總括來說，每5個治療病人會有1個發生藥物不良事件(95% CI 4 to 9)。高血糖症風險也顯著增加， OR 4.95；95% CI 2.47 ∼ 9.91。

作者結論

使用口服或注射皮質類固醇來治療慢性阻塞性肺病的急性惡化可以顯著地降低治療失敗比例、減少其他治療的需求、以及縮短住院時間。這樣的治療也增加了肺功能進步的速率以及改善呼吸困難。治療期間這些進步是持續的，但是藥物不良的風險也顯著的增加。最理想的藥物劑量及治療時間仍需進一步確立。

翻譯人

本摘要由臺北榮民總醫院鄭博斌翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

慢性阻塞性肺病的患者(肺氣腫或慢性支氣管炎)，有時會有急性發作且須住院治療。此急性惡化通常是由感染造成。以皮質類固醇治療如prednisolone, prednisone 或 cortisone已非常普遍。這次文獻回顧發現皮質類固醇治療能改善呼吸困難，使肺功能進步，縮短住院時間，以及降低其他醫療的需求。使用皮質類固醇仍有短暫的副作用發生，最理想的用法尚不明確。