Study Shows Lower-Dose Steroid Treatment May Be as Effective as High-Dose
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Reviewed By Laura J. Martin, MD
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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.
Mularski speculates that doctors may reach for the bigger guns -- IV steroids -- because they view them as a more effective way to treat COPD. But "steroids are not without significant side effects, especially for hospitalized [patients], and you would want to avoid this by giving the right amount and not too much," he says.
Bigger is not always better when it comes to COPD treatment, says Neil Schachter, MD, a professor of pulmonary medicine and medical director of the respiratory care department at Mount Sinai Center in New York City.
"IV steroids have no benefit over the less expensive oral steroids in terms of hospital stays and mortality," he says.
When asked by WebMD if this study could change practice, Schachter says "while I don't think that this study will immediately change how doctors treat exacerbations, it certainly puts the spotlight on the need to refine criteria for IV steroid therapy."
But "these guidelines are guideposts, not laws," he says. "The changing recommendations and the need to individualize treatment make doctors reluctant to embrace every new study or guideline as soon as it is published," he says.
"I use inhaled and oral steroids in the patients I see in my office," Schachter says. "If someone is in severe distress in my office, I might give them an injection of steroids to rapidly relieve symptoms, knowing that there could be a significant delay if they have to go home and obtain oral medication from a pharmacy. Many of the patients with a COPD exacerbation come through the emergency room where they are given IV steroids as a reflex."
He says that one of the presumed criteria for admission to the hospital is that they need IV treatment. "Once they are on IV steroids, there may be an inertia to switch to oral medication as the exacerbation is brought under control," he says, adding that most of these individuals are already on oral steroids when they arrive at the emergency room.
SOURCES: Lindenauer P. The Journal of the American Medical Association, 2010; vol 303: pp 2359-2367.
Krishnan J.A. The Journal of the American Medical Association, 2010; vol 303: pp 2409-2410.
Richard A. Mularski, MD, clinical investigator, pulmonologist, Kaiser Permanente Center for Health Research, Portland, Ore.
Neil Schachter, MD, professor, pulmonary medicine; medical director, respiratory care department, Mount Sinai Center, New York City.
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