Steroid Use in Acute Exacerbations of COPDKatherine Kielts, Pharm.D.

PGY2 Critical Care Resident

St. Vincent Indianapolis Hospital

September 17, 2015This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

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Pathophysiology of COPD

http://www.nhlbi.nih.gov/health//dci/Diseases/Copd/Copd_WhatIs.html

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Rationale for Steroid Use

• Reduce capillary permeability• Inhibit neutrophil degranulation• Inhibit prostaglandins

Rationale for Steroid Use

Rodriquez-Rosin. Thorax. 2006Prednisone. Micromedex. 2015http://conditions.healthguru.com/video/copd-complications

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Steroids: Benefits and Risks

Walters. Cochrane Libr. 2009 Bahloul. Am J Ther. 2013 Rodriquez-Rosin. Thorax. 2006 Alia. Arch Intern Med. 2011Vrie. BMC Fam Pract. 2013

Benefits RisksImprovement in FEV1 Hypertension

Reduce rate of • 30 day hospital readmission• Need for mechanical

ventilation• Length of ICU and hospital

stay• Severity of dyspnea• Re-exacerbation

Hyperglycemia

Increased risk of infection

Fluid retention

Adrenal suppression

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The REDUCE Trial

• GOLD Guideline recommendation: prednisone 40mg daily for 5 days

• Objective: Prednisone 40mg daily x 5 days versus prednisone 40mg daily x 14 days (n = 314)

• Primary outcome: Time to next exacerbation• Results

• No difference in re-exacerbation rates or steroid-related adverse effects

• Less cumulative steroid exposure in short-term group

• Conclusions• Five days is noninferior to 14 days

Leuppi. JAMA. 2013GOLD Guidelines. 2015

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REDUCE Limitations

• Exclusion Criteria• History of asthma• Radiological diagnosis of pneumonia• Estimated survival of less than 6 months due to severe

comorbidity

• Standardized treatment• Lack of standardization of steroid dosing

Leuppi. JAMA. 2013

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Steroid Use in Mechanically Ventilated Patients

• Very limited data on treatment of acute COPD exacerbations in patients requiring mechanical ventilation

• Most studies conducted outside the ICU• Exclusion of mechanically ventilated patients• Mechanical ventilation = treatment failure

Abroug. Eur Respir J. 2014Alia. Arch Intern Med. 2011GOLD Guidelines. 2014Kiser Am J Respir Crit Care Med. 2014

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Readmission Reduction and Hospital Discharge

• Steroid and/or antibiotic instruction

• Assess and educate home maintenance pharmacotherapy

• Inhaler technique

• Exacerbation prevention education

• Plan follow-up visit

• Assess need for oxygen therapy

GOLD Guidelines. 2015

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Learning Assessment Question

What is the steroid dose and duration recommended by the GOLD Guidelines per the REDUCE trial?

A. Prednisone 40mg by mouth daily x 14 days

B. Methylprednisolone 40mg IV daily x 5 days

C. Prednisone 40mg by mouth daily x 5 days

D. Methylprednisolone 40mg IV daily x 14 days

Steroid Use in Acute Exacerbations of COPDKatherine Kielts, Pharm.D.

PGY2 Critical Care Resident

St. Vincent Indianapolis Hospital

September 17, 2015