ArticlesOral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial
Introduction
Chronic obstructive pulmonary disease (COPD) is an important cause of death worldwide and exacerbations of this disease commonly lead to hospital admission (1250 per year in our 350 000 health district) and increased cost. The treatment of exacerbations of COPD is controversial. Guidelines1, 2 have made recommen-dations about prescribing, but although there are clear indications for antibiotic and bronchodilator use, they state that the use of oral corticosteroids is based on common practice and is not evidence based.
When given to stable COPD patients, systemic corticosteroids significantly increase the forced expiratory volume in 1 s (FEV1) in only 10% of cases,3 whereas inflammatory-mediator production is not influenced by this treatment.4 Moreover, continued use of oral corticosteroids in COPD patients is associated with corticosteroid myopathy,5 which may be potentially important for patients with frequent exacerbations who are treated with these drugs.
Several studies have investigated the outcome of systemic use of corticosteroids in exacerbations of COPD with conflicting results. One study of 96 patients suggested that there was no effect of methylprednisolone in preventing admission to hospital after 5 h treatment in the emergency room,6 although a later, randomised double-blind study found that the readmission rate was lower in patients given treatment.7 In a randomised controlled trial, Albert and colleagues8 noted significant improvements in FEV1 before bronchodilation in the first 3 days of admission in 22 patients given intravenous methylprednisolone, but improvements in FEV1 after bronchodilation were less obvious. In another randomised controlled trial, 27 patients fit enough for discharge from the emergency room were followed up.9 The 13 treated patients showed greater improvement in FEV1 and the partial pressure of oxygen in arterial blood than did the 14 untreated patients. The Veterans Affairs Cooperative study group has completed a study of the effects of high-dose systemic corticosteroids on exacerbations of COPD.10 The primary endpoint was treatment failure, rates of which were significantly lower in the glucocorticoid-treated groups than in the placebo group.
Most COPD patients admitted with exacerbations in the UK, New Zealand, and Australia11, 12, 13 are treated with 30–40 mg oral prednisolone. We investigated the hypothesis in a prospective, randomised, double-blind, placebo-controlled trial that in more severe patients, oral corticosteroids administered in these doses would not modify the rate of improvement of lung function or significantly affect the course of hospital stay.
Section snippets
Patients
Patients with a diagnosis of COPD presenting to the accident and emergency department of University Hospital Aintree, Liverpool, were eligible for entry into the study if they had a history of increased breathlessness and at least two of the following symptoms for 24 h or more: increased cough frequency or severity, increased sputum volume or purulence, and increased wheeze. We included patients who were aged 40–80 years, had a history of at least 20 pack-years of cigarette smoking, and had
Results
We screened 246 patients for the study, and 60 met the inclusion criteria (figure 1). The most common reason for exclusion was previous treatment with oral corticosteroids before attending the accident and emergency department. Of the four patients refusing consent, three declined because they refused oral corticosteroids after being told of possible side-effects and one because she did not wish to participate in a clinical trial.
29 patients were randomly assigned active treatment and 27 were
Discussion
Any treatment that can hasten the resolution and lower the costs of exacerbations of COPD17, 18 is welcomed. Data from randomised trials in outpatients suggest that oral corticosteroids can increase the rate of resolution of the attack, but data have only been seen in short-term treatment of inpatients and the impact on health costs was unclear. We found significant differences in the rate of improvement of FEV1 before and after bronchodilation compared with placebo, which suggests that the
References (23)
- et al.
A randomised controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of chronic obstructive pulmonary disease
Chest
(1989) - et al.
Early corticosteroid use in acute exacerbations of chronic airflow limitation
Am J Emerg Med
(1996) - et al.
Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study
Lancet
(1997) - et al.
Mortality by cause for eight major regions of the world: Global Burden of Disease Study
Lancet
(1997) - et al.
Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service
Lancet
(1998) BTS guidelines for the management of chronic obstructive pulmonary disease. The COPD guidelines group of the standard of care committee of the BTS
Thorax
(1997)- et al.
Optimal assessment and management of chronic obstructive pulmonary disease (COPD)
Eur Respir J
(1995) - et al.
Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease: a metaanalysis
Ann Intern Med
(1991) - et al.
Effects of inhaled and oral glucocorticoids on inflammatory indices in asthma and COPD
Am J Respir Crit Care Med
(1997) - et al.
Functional and histologic picture of steroid-induced myopathy in chronic obstructive pulmonary disease
Am J Respir Crit Care Med
(1996)
Controlled trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency
Ann Intern Med
Cited by (517)
Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary
2023, Archivos de BronconeumologiaCOPD as the new millennium began
2024, ERS MonographThe Management of Acute Exacerbations in COPD: A Retrospective Observational Study and Clinical Audit
2024, Journal of Clinical MedicineGold 2023: Highlights for primary care
2023, npj Primary Care Respiratory Medicine