Publish in this journal
Journal Information
Vol. 53. Num. 11.November 2017Pages 603-658
Visits
214
Vol. 53. Num. 11.November 2017Pages 603-658
Original Article
DOI: 10.1016/j.arbr.2017.09.007
Treatment With Systemic Steroids in Severe Chronic Obstructive Pulmonary Disease Exacerbations: Use of Short Regimens in Routine Clinical Practice and Their Impact on Hospital Stay
Tratamiento con esteroides sistémicos en agudización grave de enfermedad pulmonar obstructiva crónica: empleo de pautas cortas en práctica clínica habitual y relación con la estancia hospitalaria
Visits
214
Pedro J. Marcosa,
Corresponding author
, Irene Nieto-Codesidoa, Santiago de Jorge Dominguez-Pazosa, Arturo Huertab, Eduardo Márquezc, Alejandro Maisoa, Rodrigo Verdeald, Isabel Otero-Gonzáleza, Marina Blanco-Aparicioa, Carmen Montero-Martíneza
a Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC) Sergas Universidade da Coruña (UDC), As Xubias, A Coruña, Spain
b Servicio de Neumología, Institut Clínic del Tòrax Hospital Clínic-IDIBAPS CIBER de Respiratorio, Universidad de Barcelona, Barcelona, Spain
c Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain
d Servicio de Medicina Interna, Instituto de Investigación Biomédica de A Coruña (INIBIC) Complejo Hospitalario Universitario de A Coruña (CHUAC) Sergas Universidade da Coruña (UDC), As Xubias, A Coruña, Spain
This item has received
214
Visits
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (3)
Table 1. Baseline Patient Characteristics.
Table 2. SCS Dose and Duration.
Table 3. Multivariate Analysis of the Association of Hospital Stay and Intrahospital Dose of Corticosteroids.
Show moreShow less
Abstract
Introduction

It is not known whether clinical practice guidelines for the treatment of COPD exacerbations with short courses of systemic corticosteroids (SC-SCS) are followed in clinical practice.

Method

Prospective, observational cohort study in patients admitted due to severe COPD exacerbation. The primary endpoint was the percentage of patients who received SC-SCS as treatment for severe exacerbation (doses of 200–300mg for 5–6 days). Secondary variables were percentage of patients with duration or reduced dose, dose in the first 24h, days of intravenous systemic corticosteroids (SCS), and duration of hospital length of stay (LOS). Simple linear regression was performed with LOS as a dependent variable and multivariate analysis with factors associated with LOS.

Results

158 patients were evaluated. 4.4% (7) patients received SC-SCS, 8.7% received a reduced dose and duration was reduced in 15.8%. The median dose and duration of SCS were 602.5mg (200–1625) and 14 (4–36) days, respectively. We observed an association between days of SCS and LOS (P<.001) and doses of intrahospital SCS and LOS (P<.001). Factors associated with LOS were doses of intrahospital SCS received (0.01 [95% CI: 0.007–0.013]; P<.001), days of steroid treatment (0.14 [95% CI: 0.03–0.25], P=.009) and PAFI (pO2/FiO2 ratio) at admission (−0.012 [95% CI: −0.012 to -0.002], P=.015).

Conclusions

The SCS schedules used in routine clinical practice are longer and administered at a higher dose than recommended, leading to a longer hospital stay.

Keywords:
Chronic obstructive pulmonary disease
Exacerbation
Steroids
Length of hospital stay
Hospitalization
Resumen
Introducción

Se desconoce si en la práctica clínica habitual se siguen las recomendaciones de las guías de práctica clínica con respecto al tratamiento de las exacerbaciones de la EPOC con pautas cortas (PC) de corticoesteroides sistémicos (CS).

Método

Estudio de cohortes, prospectivo y observacional en pacientes que ingresan por una agudización grave de su EPOC. La variable principal fue porcentaje de pacientes que recibían PC de CS como tratamiento en la exacerbación grave (dosis acumulada total de 200 a 300mg y una duración de 5-6 días). Las variables secundarias fueron porcentaje de pacientes con duración o dosis corta, dosis en las primeras 24horas, días de CS intravenosos y duración de la estancia hospitalaria (EH). Se realizó regresión lineal simple con días de estancia hospitalaria como variable dependiente y análisis multivariante con factores asociados a estancia hospitalaria.

Resultados

Se evaluaron 158 pacientes; 4,4% (7) pacientes recibieron una PC de CS. El 8,7% recibió un tratamiento corto y el 15,8% una duración reducida. La mediana de dosis y duración de CS fue 602,5mg (rango intercuartílico: 430-850) y 14 (rango intercuartílico: 4-36) días respectivamente. Observamos asociación entre más días de CS y una mayor EH (p<0,001) y una mayor dosis de CS intrahospitalaria e incremento de EH (p<0,001). Los factores asociados con EH fueron dosis de CS intrahospitalaria recibida (0,01 [IC 95%: 0,007-0,013]; p<0,001), días de tratamiento esteroideo (0,14 [IC 95%: 0,03-0,25]; p=0,009) y PAFI (cociente pO2/FiO2) al ingreso (–0,012 [IC 95%: –0,012 a –0,002]; p=0,015).

Conclusiones

Las pautas de CS empleadas en la práctica clínica habitual son más prolongadas y a una mayor dosis que las recomendadas, asociando una mayor estancia hospitalaria.

Palabras clave:
Enfermedad pulmonar obstructiva crónica
Agudización
Esteroides
Estancia hospitalaria
Hospitalización
Full Text
Introduction

The natural history of chronic obstructive pulmonary disease (COPD) is characterized by intermittent episodes of exacerbation. Exacerbations are associated with an accelerated loss of lung function,1 poorer quality of life2 and greater mortality,3 associated mainly with more severe exacerbations requiring hospitalization.4 Optimal management of severe exacerbations is essential if prognosis is to improve. Hospital treatment of COPD exacerbations (COPDE) includes the use of oxygen, antibiotics, bronchodilators, and systemic corticosteroids (SCS). SCS are useful for improving lung function and symptoms, improving the 30-day treatment failures rate, and reducing hospital stay.5 However, no benefit in terms of mortality has been demonstrated, and the use of SCS is associated with increased side effects, the most frequent being hyperglycemia.5

At present, almost all COPD clinical management guidelines recommend the use of SCS in severe exacerbations. However, the recommendations vary to some extent in terms of the appropriate dose and duration of treatment. Thus, while the GOLD 20136 guidelines recommended 30–40mg prednisone daily for 10–14 days, the NICE guidelines7 proposed a slightly shorter duration (7–14 days), and the 2012 edition of the Spanish COPD guidelines8 recommended treatment with oral prednisone 0.5mg/kg/day or equivalent until clinical improvement, with suspension of the treatment as soon as possible, preferably before 7–10 days. Following publication of the REDUCE study,9 a randomized clinical trial which showed that a 5-day regimen produced similar rates of new exacerbations at 6 months, similar mortality and less exposure to corticosteroids as a 14-day regimen (37.2% versus 38.4%; P=NS), GOLD 20146 included a recommendation for a 5-day course of 40mg prednisone/day, and repeated the same recommendation in the recent update.10 The Spanish COPD guidelines updated in 201411 include the REDUCE data, and support the use of short 5-day courses, but only in exacerbations which do not require hospitalization, even though over 90% of the patients included in the REDUCE study were hospitalized.12

Despite these recommendations, very little is known about the patterns of use of corticosteroids (dose and duration) in routine clinical practice. Our hypothesis is that, in the real world, practices vary widely, and the dose and duration of SCS are usually greater than those recommended in the clinical guidelines, and that this may impact on the duration of hospital stay.

Materials and MethodsStudy Design and Participants

This was a prospective, observational cohort study in patients seen in a tertiary hospital (Hospital Universitario de A Coruña), with a catchment area of 540000 inhabitants. The study was conducted between 1 July 2013 and 1 August 2015, and was approved by the Galician Clinical Research Ethics Committee (CREC).

We included patients older than 40 years, with a history of smoking, COPD diagnosis prior to admission defined according to the GOLD criteria (FEV1/FVC<0.7 post-bronchodilator), and a diagnosis of COPDE. Patients who were taking chronic SCS were excluded, as were those who did not receive SCS during hospitalization, and those with no history of smoking. Only the first admission was analyzed among patients who were readmitted.

Objectives

The primary study objective was to determine the percentage of patients receiving short course of SCS in the treatment of acute COPDE. A short course was defined as a cumulative dose 200–300mg prednisone or equivalent over 5–6 days. Secondary variables were the percentage of patients with a SCS duration of 5–6 days, percentage of patients with a cumulative dose of 200–300mg prednisone, dose given in the first 24h, days of intravenous SCS, and duration of hospital stay.

Data Collection

Patients were seen by the usual medical team in each department, and data were collected by the investigators. Data were collected from patients admitted to the respiratory medicine hospital ward and to one of the internal medicine wards. Demographic (age, sex, smoking status, and immunizations), laboratory and clinical data were collected from the patients. Comorbidities were assessed and the Charlson index was calculated. Functional status was evaluated using the Barthel index. COPD severity was determined from spirometric values, baseline dyspnea scale (mMRC), COPD assessment test (CAT), and exacerbation history. The severity of the current episode was assessed by calculating dyspnea, eosinopenia, consolidation, acidosis, and atrial fibrillation. Treatments received by all patients were recorded. With regard to SCS, the type, dose, duration and route of administration were recorded. Prednisone doses were used as a reference for the calculation of equivalent doses of other SCS. Finally, data on hospitalization were recorded, including days of hospital stay, resources used (ICU admission and need for mechanical ventilation), and in-hospital mortality.

Statistical Analysis

Quantitative data are expressed as mean and standard deviation and qualitative data as frequencies. Quantitative data that did not follow a normal distribution are expressed as median and interquartile range. The association between hospital stay and duration of steroid treatment and cumulative dose were evaluated using the Spearman rank correlation. Simple linear regression with days of hospital stay as the dependent variable was used to study the degree of correlation. Multivariate linear regression was performed with factors associated with hospital stay: variables with a P-value of <.05 in the univariate analysis were incorporated into this model. All statistical analyses were performed using a digital statistical program (Stata for Mac O.S., version 13.0; Statacorp Inc., USA). Values were considered significant if P<.05.

ResultsPatient Characteristics

A total of 179 patients were analyzed, of whom 21 were withdrawn from the study (6 for chronic use of corticosteroids, 11 who did not receive corticosteroids, and 4 non-smokers). The final cohort consisted of 158 patients, 88.6% of whom were men. Mean age was 69.8 (standard deviation, 9.5) years. Patient characteristics are shown in Table 1.

Table 1.

Baseline Patient Characteristics.

Demographic Data  N (%) 
Male  140 (88.6) 
Age (years)  69.8 (9.6) 
Active smoking  64 (40.5) 
Cumulative consumption (pack-years)  57 (SD=24.8) 
Influenza vaccination  96 (60.8) 
Pneumococcal vaccination  52 (32.9) 
Barthel  92.7 (SD=19.5) 
Concomitant disease
Anxiety  8 (5) 
Depression  21 (13.3) 
Osteoporosis  5 (3.2) 
Arterial hypertension  75 (47.7) 
Atrial fibrillation, atrial flutter  17 (10.7) 
Thromboembolic disease  5 (3.2) 
Abdominal aortic aneurysm  4 (2.5) 
Acute myocardial infarction  12 (7.6) 
Peripheral artery disease  20 (12.6) 
Heart failure  14 (8.9) 
Cerebral artery disease  13 (8.2) 
Hemiplegia  2 (1.3) 
Venous ulcer disease  7 (4.4) 
Mild liver disease  5 (3.2) 
Moderate-severe liver disease  3 (1.9) 
Moderate-severe renal disease  8 (5) 
Diabetes mellitus  37 (23.4) 
Diabetes with organ involvement  3 (1.9) 
Tumor  20 (12.6) 
Metastatic tumor disease  3 (1.9) 
Charlson  5.5 (SD=2) 
History of COPD
Chronic bronchitis  92 (58.2) 
History of asthma  8 (5) 
No. of exacerbations in previous yeara  2 (IQR: 0–15) 
38 (24) 
1–2  43 (27.2) 
≥2  77 (48.7) 
mMRC  2.6 (1) 
FEV1/FVC  43.8 (12.3) 
FEV1 cc  1173 (530.6) 
FEV1%  44.8 (19.1) 
FVC cc  2666 (827.2) 
FVC%  75.2 (21.1) 
BODEX  2.3 (1.29) 
Home oxygen therapy  56 (36.6) 
LAMA  122 (77.2) 
LABA-ICS  120 (75.9) 
Current admission
PAFI  257.6 (83.6) 
Eosinophils (no.)  60 (10–560) 
Eosinophils (%)  0.5 (0.06–6.2) 
CRP  1.97 (0.1–19.6) 
DECAF  1.3 (0.96) 

CI: inhaled corticosteroid; CRP: C-reactive protein; DECAF: DECAF score (Dyspnea, Eosinopenia, Consolidation, Acidemia and atrial Fibrillation); FEV1: forced expiratory volume in the first second; FVC: forced vital capacity; LABA: long-acting beta-2 agonist; LAMA: long-acting muscarinic agonist; PAFI: ratio of partial pressure arterial oxygen and fraction of inspired oxygen.

a

Includes moderate and severe exacerbations.

Dose and Duration of Treatment with Systemic Corticosteroids

Only 4.4% of the cohort (7 patients) received a short course of SCS; 8.7% (13) received an SCS dose of between 200 and 300mg; and in 15.8% (24) the duration of administration was 5–6 days. Mean SCS dose was 602.5mg (interquartile range [IQR]: 430–850), and the median duration of SCS was 14 days (IQR: 7–20) (Fig. 1). Median duration of intravenous SCS was 4 days (IQR: 2–7) (Fig. 1). Median length of hospital stay was 9 days (IQR: 7–12.5) (Table 2).

Fig. 1.
(0.11MB).

(A) Duration of steroid treatment. (B) Cumulative steroid dose.

Table 2.

SCS Dose and Duration.

Variable  Median (Interquartile Range) 
SCS dose in first 24125 (100–150) 
SCS dose during hospitalization  510 (370–695) 
SCS dose on discharge  45 (0–175) 
Total SCS dose  602.5 (430–850) 
Intravenous steroid dose  4 (2–7) 
Total days of steroid administration  14 (7–20) 
Days of hospital stay  9 (7–12.5) 

SCS: systemic corticosteroid.

SCS dose in milligrams of prednisone.

Relationship of Dose and Duration of Treatment With Systemic Steroids and Hospital Stay

A positive association was observed between the dose of SCS and hospital stay (P<.001) (rho=0.48) and days of SCS and hospital stay (P<.001) (rho=0.49) (Fig. 2). The multivariate analysis showed that a greater length of hospital stay was independently associated with a higher dose of SCS during admission after adjustment for other clinical variables, such as days of steroid treatment and PaFi (hazard ratio pO2/FiO2) at admission (Table 3).

Fig. 2.
(0.17MB).

(A) Association between hospital stay and the cumulative dose of prednisone during admission. (B) Association between hospital stay and duration of treatment with systemic steroids.

Table 3.

Multivariate Analysis of the Association of Hospital Stay and Intrahospital Dose of Corticosteroids.

Variable  Coefficient  SD  P 
Intrahospital dose of SCS (mg prednisone)  0.01  0.001  <.001 
Total days of SCS administration  0.14  0.05  .009 
PAFI  −0.012  0.005  .015 

PAFI: ratio of partial pressure arterial oxygen and fraction of inspired oxygen; SCS: systemic corticosteroid.

Discussion

The dose and duration of treatment with SCS in COPD exacerbations in clinical practice are much higher than those recommended in clinical practice guidelines, and are associated with increased hospital stay. Treatment with SCS in patients admitted to hospital with severe exacerbation of COPD is a practice that is clearly widespread in hospitals. Indeed, the AUDIPOC study13 showed that more than 90% of the patients who had been admitted for COPDE received treatment with SCS.

This unquestionable evidence on the use of these drugs prompts us to ask whether they might be less beneficial in some subgroups, such as patients with low eosinophil levels14–16 and patients whose exacerbation is clearly caused by infection,17 or if the efficacy of high doses administered by inhalation would be comparable to that of systemic administration.18

In this study, we observed that instead of the recommended dose of 200mg (40mg/day for 5 days), patients in clinical practice were receiving 3 times this amount. This could be explained in several ways: (a) a delayed switch to oral treatment; (b) doses of corticosteroid used in asthma being transferred to COPD; and (c) the risk of adrenal crisis due to an abrupt withdrawal. It is interesting to note that more than 50% of the recommended dose is administered in the first 24h, a period during which the patient is generally treated in the emergency department. In addition, we found that the recommended short duration of administration (5 days) is almost is tripled in clinical practice. Despite evidence that oral administration of steroids is not inferior to intravenous administration,19 and that this is the route of choice in some guidelines,6,10 we found in this study that the average time to switch to oral administration was 5 days. Delays in the switch to oral administration, whether for corticosteroids or antibiotics, would require the patient to remain hospitalized for intravenous administration, thus extending hospital stay. It is important to remember that patients receiving corticosteroids are at risk of hyperglycemia. Excessive exposure to corticosteroids, whether from excessively high doses or prolonged duration of treatment, may cause hyperglycemia,20 and concomitant hyperglycemia can also prolong hospital stay. Accumulated doses of corticosteroid can also cause musculoskeletal effects which may become a problem as the frequency of exacerbations increases. The most worrying of these effects are fractures, infections and other metabolic changes.21

This study has a number of limitations that should be mentioned. The most obvious is that its single-center design prevents any generalization of our conclusions. However, we suspect that our observations hold true for other centers, or that the situation is even be worse than our findings suggest. In the AUDIPOC study, for example, 72% of patients who received corticosteroids during admission continued to receive them on discharge, compared to 52% in our series. A second limitation is that the study was conducted under conditions of routine clinical practice, and some of the study investigators were directly involved in the clinical management of these patients, a situation which may have generated some bias when deciding on the recommended dose and treatment duration. Moreover, the patients were not classified by phenotypes, so we cannot be sure, but merely suspect, that patients with asthma-COPD overlap behave differently. Finally, while we found an independent association between the duration of hospital stay and the dose and duration of steroids, many other factors which might have a direct effect on clinical practice were not analyzed, such as social considerations, hospital inefficiencies, continued care after discharge, etc.

In summary, this study shows that systemic corticosteroid regimens used in clinical practice in the treatment of severe exacerbations of COPD are administered for much longer periods and at higher doses than recommended, a practice that has a direct impact on hospital stay. More studies are needed to confirm how generalized this practice is in our setting and to determine the possible medium- and long-term consequences.

Conflict of Interests

The authors state that they have no conflict of interests.

References
[1]
G.C. Donaldson,T.A.R. Seemungal,A. Bhowmik,J.A. Wedzicha
Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease
Thorax, 57 (2002), pp. 847-852
[2]
T.A.R. Seemungal,G.C. Donaldson,E.A. Paul,J.C. Bestall,D.J. Jeffries,J.A. Wedzicha
Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease
Am J Respir Crit Care Med, 157 (2012), pp. 1418-1422 http://dx.doi.org/10.1164/ajrccm.157.5.9709032
[3]
J.J. Soler-Cataluna,M.Á. Martínez-García,P. Román Sánchez,E. Salcedo,M. Navarro,R. Ochando
Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease
[4]
S. Suissa,S. Dell’Aniello,P. Ernst
Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality
[5]
J.A.E. Walters,D.J. Tan,C.J. White,R. Wood-Baker
Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease
Cochrane Database Syst Rev, 12 (2014), pp. CD006897
[6]
J. Vestbo,S.S. Hurd,A.G. Agustí,P.W. Jones,C. Vogelmeier,A. Anzueto
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary
Am J Respir Crit Care Med, 187 (2013), pp. 347-365 http://dx.doi.org/10.1164/rccm.201204-0596PP
[7]
National Institute for Health and Clinical Excellence
Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update)
National Clinical Guideline Centre, (2010)
[accessed 26.12.14]. Available in: http://www.nice.org.uk/CG101
[8]
Guía de práctica clínica para el diagnóstico tratamiento de pacientes con enfermedad pulmonar obstructiva crónica (EPOC)
Guía española de la EPOC (GesEPOC)
Arch Bronconeumol, 48 (2012), pp. 2-58 http://dx.doi.org/10.1016/S0300-2896(12)70044-3
[9]
J.D. Leuppi,P. Schuetz,R. Bingisser,M. Bodmer,M. Briel,T. Drescher
Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease
[10]
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2016 [accessed 27.03.16]. Available in: http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016
[11]
M. Miravitlles,J.J. Soler-Cataluña,M.D. Calle,J. Molina,P. Almagro,J.A. Quintano
Guía española de la EPOC (GesEPOC). Actualización 2014
Arch Bronconeumol, 50 (2014), pp. 1-16 http://dx.doi.org/10.1016/S0300-2896(14)70070-5
[12]
P.J. Marcos,A. Huerta,E. Márquez-Martín
2014 GesEPOC and systemic steroids in chronic obstructive pulmonary disease (COPD) exacerbation: an update
Arch Bronconeumol, 51 (2015), pp. 360 http://dx.doi.org/10.1016/j.arbres.2013.11.006
[13]
F. Pozo-Rodríguez,J.L. López-Campos,C.J. Alvarez-Martínez,A. Castro-Acosta,R. Agüero,J. Hueto
Clinical audit of COPD patients requiring hospital admissions in Spain: AUDIPOC study
[14]
M. Bafadhel,S. McKenna,S. Terry,V. Mistry,C. Reid,P. Haldar
Acute exacerbations of chronic obstructive pulmonary disease
Am Resp Crit Care Med, 184 (2011), pp. 662-671
[15]
M. Bafadhel,L. Davies,P.M.A. Calverley,S.D. Aaron,C.E. Brightling,I.D. Pavord
Blood eosinophil guided prednisolone therapy for exacerbations of COPD: a further analysis
Eur Respir J, 44 (2014), pp. 789-791 http://dx.doi.org/10.1183/09031936.00062614
[16]
M. Bafadhel,S. McKenna,S. Terry,V. Mistry,M. Pancholi,P. Venge
Blood eosinophils and outcomes in severe hospitalized exacerbations of COPD
[17]
S. Sethi,A. Anzueto,M. Miravitlles,P. Arvis,J. Alder,D. Haverstock
Determinants of bacteriological outcomes in exacerbations of chronic obstructive pulmonary disease
[18]
Z. Ding,X. Li,Y. Lu,G. Rong,R. Yang,R. Zhang
A randomized, controlled multicentric study of inhaled budesonide and intravenous methylprednisolone in the treatment on acute exacerbation of chronic obstructive pulmonary disease
Respir Med, 121 (2016), pp. 39-47 http://dx.doi.org/10.1016/j.rmed.2016.10.013
[19]
Y.P. De Jong,S.M. Uil,H.P. Grotjohan,D.S. Postma,H.A.M. Kerstjens,J.W.K. van den Berg
Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study
Chest, 132 (2007), pp. 1741-1747 http://dx.doi.org/10.1378/chest.07-0208
[20]
J.M. Baker,H.A. Pace,J.B. Ladesich,S.D. Simon
Evaluation of the impact of corticosteroid dose on the incidence of hyperglycemia in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease
Hosp Pharm, 51 (2016), pp. 296-304 http://dx.doi.org/10.1310/hpj5104-296
[21]
T.A. Schweiger,M. Zdanowicz
Systemic corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease
Am J Health Syst Pharm, 67 (2010), pp. 1061-1069 http://dx.doi.org/10.2146/ajhp090293

Please cite this article as: Marcos PJ, Nieto-Codesido I, de Jorge Dominguez-Pazos S, Huerta A, Márquez E, Maiso A, et al. Tratamiento con esteroides sistémicos en agudización grave de enfermedad pulmonar obstructiva crónica: empleo de pautas cortas en práctica clínica habitual y relación con la estancia hospitalaria. Arch Bronconeumol. 2017;53:611–615.

Copyright © 2017. SEPAR
Idiomas
Archivos de Bronconeumología (English Edition)

Subscribe to our Newsletter

Article options
Tools
Cookies policy
To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.

Are you a health professional able to prescribe or dispense drugs?