COPD使用類固醇

Steroid Dosage and Route in Patients Admitted for COPD
Oral low-dose use was associated with less treatment failure than was high-dose parenteral use.

Patients admitted for chronic obstructive pulmonary disease (COPD) usually receive systemic steroids, which have been associated with better outcomes in several prior randomized trials, but the best dose is still in question. Several major clinical practice guidelines recommend low-dose oral steroids.

In a retrospective cohort study, based on data from 414 U.S. hospitals, Massachusetts investigators compared outcomes in nearly 80,000 patients admitted for COPD to non–intensive care unit settings. About 74,000 received parenteral steroids (equivalent to a median dose of 600 mg of prednisone total for the first 2 days), and the rest received oral prednisone (median, 60 mg for the first 2 days). Treatment failure — defined as need for mechanical ventilation after the first 2 days, death, or readmission for COPD within 30 days — occurred in 11% of all patients.

In analyses adjusted for about 50 clinical and demographic variables, as well as propensity scores, treatment failure was 16% lower in patients who received oral low-dose steroids than in those who received parenteral steroids; length of stay and cost were about 10% lower in the low-dose group.

Comment: Although this study was retrospective, its sophisticated analyses convinced editorialists that the results should influence clinical practice and that a randomized controlled trial would be prohibitive in size and cost and is unnecessary. A worrisome secondary finding is that the vast majority of COPD patients received high-dose parenteral steroids, despite the contrary recommendations of major national and international guidelines — including those of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

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Thomas L. Schwenk, MD
Published in Journal Watch General Medicine June 24, 2010

Citation(s): Lindenauer PK et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010 Jun 16; 303:2359. (http://dx.doi.org/10.1001/jama.2010.796)