Different Durations of Corticosteroid Therapy for Exacerbations of Chronic Obstructive Pulmonary Disease

Abstract

How does efficacy differ between short (≤ 7 days) and conventional (> 7 days) systemic corticosteroid treatment in adults with acute exacerbations of chronic obstructive pulmonary disease (COPD)?Chronic obstructive pulmonary disease is the fourth leading cause of death worldwide and is projected to become the third leading cause of death by 2020.1 In the United States, COPD affects 16 million people—and millions more in whom COPD has not been diagnosed or is not being treated.2 As such, COPD is an important public health issue that requires thorough attention to promote awareness, provide diagnoses, and implement appropriate treatment.Chronic obstructive pulmonary disease comprises a group of conditions that block airflow and cause breathing-related problems, including emphysema and chronic bronchitis.2 Persistent symptoms and airflow limitations characterize COPD; these are due to airway abnormalities often caused by substantial exposure to harmful particles (eg, cigarette smoke). This exposure results in lung inflammation, which in turn can destroy tissue and cause gas exchange abnormalities.1Over the course of COPD, patients often experience exacerbations that are usually precipitated by infection. During these exacerbations, symptoms such as breathlessness, cough, and phlegm production markedly worsen, requiring additional treatment or admission to a hospital. Current high-quality evidence supports treating these exacerbations of COPD with systemic corticosteroids (via the oral or parenteral route) to reduce the likelihood of treatment failure and relapse, shorten the hospital length of stay, and improve lung function and symptoms.3 Although systemic corticosteroids are effective, their use in treating COPD is associated with potential adverse effects, including fluid retention, hypertension, diabetes mellitus, adrenal suppression, and osteoporosis.4International guidelines for managing COPD vary with respect to the duration of corticosteroid treatment (range 7-14 days).5 Considering its potential adverse effects, it is important to determine the most beneficial duration of corticosteroid treatment. The purpose of this systematic review was to assess whether a short course (≤ 7 days) of corticosteroid treatment was as effective as, and whether it caused fewer side effects than, a course of usual length (> 7 days).This summary describes a systematic review, updated in 2017 by Walters et al,5 that included data from 8 randomized controlled trials, with a combined total of 582 participants. The review explored 3 primary outcomes:Walters et al5 independently assessed the risk of bias—including selection bias, performance bias, detection bias, attrition bias, reporting bias, and publication bias—in each study. They resolved any disagreements by reviewing the data together and through discussion.The authors used odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) as measures of treatment effects between various comparisons and outcomes. They applied the internationally approved Grading of Recommendation, Assessment, Development and Evaluation approach to assess the quality of the evidence for each outcome. This approach includes 4 levels of evidence quality: (1) high, indicating that further research is very unlikely to change the confidence in the conclusions; (2) moderate, indicating that further research is likely to have an important impact on the confidence in the conclusions and may change the conclusions; (3) low, which signals that further research is very likely to have an important impact on the confidence in the conclusions and is likely to change the conclusions; and (4) very low, meaning that the conclusions are not certain.6The systematic review compared differences among patients receiving the shorter and longer treatment courses, with the following main results:The main outcomes explored in this systematic review suggest that shorter courses (≤ 7 days) of systemic corticosteroids are as effective as longer courses (> 7 days) for treating adults with acute exacerbations of COPD. This review also suggests that the likelihood is low that shorter courses of systemic corticosteroids (~ 5 days) lead to worse outcomes than do longer courses (10-14 days).In examining the findings of this systematic review, health care teams should consider evaluating the benefit of shorter corticosteroid regimens in treating acute exacerbations of COPD. Shorter durations have been shown to be just as effective as long-term corticosteroid use, with no significant difference regarding the potential adverse effects.As nurses caring for critically ill patients, we need to advocate for the best evidence-based treatment. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is the most appropriate choice to implement in our particular context.