Tuberculosis and HIV infection in Africa.

Abstract

<h3>BACKGROUND:</h3> COPD guidelines report that systemic corticosteroids are preferred over inhaled corticosteroids in the treatment of exacerbations, but the inhaled route is considered to be an option. <h3>OBJECTIVES:</h3> To conduct a systematic review and meta-analysis regarding the efficacy and safety of inhaled corticosteroids for COPD exacerbations. The second objective was to provide pharmacologic and clinical perspectives of inhaled corticosteroids for COPD exacerbations. <h3>METHODS:</h3> The primary outcome was a change in FEV₁ baseline versus the last measured value. Secondary outcomes were a change in (P_aO₂) and (P_aCO₂) baselines versus the last measured values; FEV₁, P_aO₂, and P_aCO₂ at 24 or 72 h; and hyperglycemia. <h3>RESULTS:</h3> Each of the 9 studies included in the meta-analysis was conducted in subjects who were hospitalized and not critically ill. Our meta-analysis indicated that high-dose nebulized budesonide 4–8 mg/d was noninferior to systemic corticosteroids on the change in FEV₁ between baseline and the last measured value (mean difference of 0.05, 95% CI −0.01 to 0.12, <i>P</i> = .13) and P_aCO₂ (mean difference of −1.14, 95% CI −2.56 to 0.27, <i>P</i> = .11) but of inferior efficacy for P_aO₂ changes (mean difference of −1.46, 95% −2.75 to −0.16, <i>P</i> = .03). Hyperglycemia was less frequent with high-dose nebulized budesonide (risk ratio, 0.13; 95% CI 0.03–0.46; <i>P</i> = .002). <h3>CONCLUSIONS:</h3> Based on our meta-analysis with a change in FEV₁ as the primary end point, high-dose nebulized budesonide was an acceptable alternative to systemic corticosteroids in hospitalized subjects with COPD exacerbations who were not critically ill. Additional well-designed prospective studies are needed in both the acute care and ambulatory settings. We provide perspective on how this evidence might be applied in clinical practice.