Outcomes Associated with Corticosteroid Dosage in Critically Ill Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease.
Am J Respir Crit Care Med. 2014 Mar 11;
Authors: Kiser TH, Allen RR, Valuck RJ, Moss M, Vandivier RW
Rationale: Studies evaluating corticosteroid (CS) dosing for patients hospitalized with an acute exacerbation of COPD (AECOPD) have largely excluded patients admitted directly to the intensive care unit (ICU), and none have evaluated the effect of CS dosing regimens on mortality. Objectives: Examine the effectiveness and safety of lower-dose versus high-dose CS in patients admitted to the ICU with an AECOPD. Methods: This pharmacoepidemiological cohort study evaluated ICU patients with AECOPD admitted to one of 473 hospitals and treated with CS within the first 2 days between January 1, 2003 and December 31, 2008. Patients were grouped into lower-dose (methylprednisolone ≤240mg/day) or high-dose (methylprednisolone>240mg/day) groups based on CS dosage on hospital day 1 or 2. The primary outcome was hospital mortality. Measurements and Main Results: 17,239 patients were included, 6,156 (36%) were in the lower-dose and 11,083 (64%) in the high-dose CS group. After propensity score matching and adjustment for unbalanced covariates, lower-dose CS was not associated with a significant reduction in mortality (OR 0.85; 95% CI 0.71- 1.01; p = 0.06), but it was associated with reduced hospital (-0.44 days; 95% CI -0.67, -0.21; p < 0.01) and ICU (-0.31 days; 95% CI -0.46, -0.16; p<0.01) length-of-stay, hospital costs (-$2,559; 95% CI -$4,508, -$609; p=0.01), length of invasive ventilation (-0.29 days; 95% CI -0.52 to -0.06; p=0.01), need for insulin therapy (22.7% vs. 25.1%, p<0.01) and fungal infections (3.3% vs. 4.4%, p<0.01). Conclusions: Two thirds of patients admitted to the ICU with an AECOPD are treated with high doses of corticosteroids that are associated with worse outcomes and more frequent adverse effects. Lower dosage strategies should be encouraged for patients admitted to the ICU and the optimum dose should be determined through clinical trials.
PMID: 24617842 [PubMed - as supplied by publisher]