High-dose intravenous corticosteroids are widely prescribed for patients admitted to the hospital with acute exacerbation of COPD, despite guidelines recommending oral steroids at lower doses (for a synthesis of 3 guidelines, see National Guideline Clearinghouse 2010 May 24:COPD_ACUTE10). A recent retrospective analysis of 79,985 hospitalized patients who received steroids for COPD exacerbation at 414 centers in the United States found that 92% were initially treated with IV steroids, while only 8% initially received oral steroids. However, outcome measures suggest that oral steroids for initial treatment may be at least as effective as IV steroids (level 2 [mid-level] evidence). Over the first 2 days, median doses (prednisone equivalents) were 60 mg in patients receiving oral steroids and 600 mg in patients receiving IV steroids. A total of 1,356 patients (22%) initially prescribed oral steroids were switched to IV steroids during hospitalization. The primary measure was treatment failure, defined as the composite of 3 outcomes: in-hospital mortality, initiation of mechanical ventilation after the second hospital day, and readmission for acute exacerbation of COPD within 30 days. Treatment failure occurred in 10.3% of the oral group and 10.9% of the IV group (not significant). In-hospital mortality was significantly lower in the oral group (1% vs. 1.4%, p = 0.01).
To control for potential baseline differences, a subgroup analysis compared patients from the 2 groups that were matched by “propensity scores” for initial treatment with oral steroids. Propensity scores were based on patient characteristics (including demographic and insurance factors), comorbidities, all other early treatments and diagnostic tests, and hospital characteristics. In this comparison, initial treatment with oral steroids was associated with reduction in risk of treatment failure (odds ratio 0.84, 95% CI 0.75-0.95), shorter hospital stay (odds ratio 0.9, 95% CI 0 0.88-0.91) and lower hospital costs (odds ratio 0.91, 95% CI 0.89-0.93) (JAMA 2010 Jun 16;303(23):2359).
For more information, see the Acute exacerbation of chronic bronchitis topic in DynaMed.