COPD Patients May Be Overtreated With Steroids
Study Shows Lower-Dose Steroid Treatment May Be as Effective as High-Dose
June 16, 2010 -- More than 90% of acutely ill people who are hospitalized for chronic obstructive pulmonary disease (COPD) receive high doses of IV steroids, even though lower-dose oral steroids may be just as effective, a study shows.
The findings appear in the June 16 issue of The Journal of the American Medical Association.
COPD is a progressive, debilitating lung disease that makes it increasingly hard to breathe. Symptoms include coughing, wheezing, shortness of breath, and chest tightness. COPD is the fourth leading cause of death in the U.S., and one of the 10 leading causes of hospitalizations.
"In sharp contrast to the leading clinical guidelines, the vast majority of patients hospitalized for acute exacerbation of COPD were initially treated with high doses of corticosteroids administered intravenously," conclude study researchers led by Peter K. Lindenauer, MD, of Baystate Medical Center in Springfield, Mass. This practice is not associated with "any measurable benefit and at the same time exposes patients to the risks and inconvenience of an intravenous line, potentially unnecessarily high doses of steroids, greater hospital costs, and longer lengths of stay."
Steroids are considered to be a beneficial way to treat acute exacerbations of COPD, but the best dosages and the best way to deliver them is not fully understood. Most clinical guidelines recommend treatment with 20 milligrams to 60 milligrams of prednisone (an oral steroid) once daily.
Researchers looked at how steroids were used among people hospitalized for COPD at more than 400 hospitals during 2006 and 2007. They then compared outcomes among patients treated with oral steroids and patients who received higher doses of IV steroids during the first two days of their hospitalization for COPD.
Fully 92% of 79,985 patients were treated with high-dose IV steroids, compared with 8% who received oral steroids, the study shows. Overall, 1.4% of people treated with IV steroids died while they were hospitalized, compared with 1% of those who received oral steroids.
Researchers also developed a composite measure or a combination of several outcomes that together indicate treatment failure. This composite measure included mechanical ventilation after day two and death in the hospital or readmission within 30 days after discharge. The researchers found that 10.9% of patients in the IV group failed treatment, compared with 10.3% of people in the oral steroid group.
Patients treated with oral steroids also had shorter hospital stays and less cost associated with treatment, compared to patients who received IV steroids.
"Providers need to keep up on the guidelines," says Richard A. Mularski, MD, a clinical investigator and a pulmonologist at Kaiser Permanente Center for Health Research in Portland, Ore. Mularski is a co-author of an editorial that accompanied the new study.