Systemic corticosteroids are a cornerstone of treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), yet their optimal route of administration is uncertain.
We conducted a retrospective cohort study of patients hospitalized for AECOPD in 2001 at 360 hospitals throughout the United States. Patients were included in our analysis if they were ≥40 years, had a principal diagnosis of AECOPD or a principal diagnosis of respiratory failure paired with a secondary diagnosis of AECOPD, and had been treated with systemic corticosteroids during the first 2 hospital days. Patients transferred from another acute care facility, those admitted directly to the ICU, and patients whose length of stay was <2 days were excluded. We developed multivariable models to estimate the effect of the initial route of steroid administration (intravenous vs. oral) on a composite measure of treatment failure, defined as the initiation of mechanical ventilation after the 2nd hospital day, death during hospitalization, or readmission within 30 days of discharge. Models adjusted for a wide range of patient (eg demographics, comorbidities), physician (specialty) and hospital factors (eg size, teaching status), diagnostic tests associated with severity (eg ABG measurement), other treatments (eg bronchodilators, antibiotics, noninvasive ventilation), and propensity for treatment with oral (PO) steroids. Generalized estimating equations were used to account for the effects of patient and physician clustering.
Of the 37,267 patients who met our enrollment criteria, 34,430 (92%) were initially treated with intravenous (IV) steroids, whereas 2846 (8%) received treatment by mouth. Mean steroid exposure over the first 2 hospital days, expressed in prednisone equivalents, was 128 mg for patients treated orally and 763 mg for those in the intravenous group. When compared with patients treated with IV steroids, those given PO steroids were slightly older (71 vs. 70 years), more likely to be female (62% vs. 60%), less likely to be white (75% vs. 77%), more likely to have heart failure (25% vs. 20%), and less likely to undergo early ABG testing (47% vs. 61%). Inpatient mortality (1.7% vs. 1.6%) and initiation of mechanical ventilation after hospital day 2 (1.3% vs. 1.4%) were similar among the 2 groups of patients; however, those treated with PO steroids were more likely to be readmitted within 30 days (20% vs. 18%, P = .04), and their risk of treatment failure was higher (22% vs. 20%, P = .05). Five hundred and ninety patients (21%) initially treated with oral steroids were later switched to IV therapy. After multivariable adjustment, the risks of treatment failure associated with PO and IV steroid administration were similar (OR 1.04, 95% CI 0.94‐1.14).
As an initial treatment strategy for patients with AECOPD, PO and IV routes of steroid administration are associated with similar outcomes. Opportunities exist to reduce unnecessary steroid exposure and improve efficiency by increasing the use of PO steroids.
P. Lindenauer, none; M. Rothberg, none; E. Benjamin, none; Y. Lee, none; P. Pekow, none.
To cite this abstract:Lindenauer P, Rothberg M, Benjamin E, Lee Y, Pekow P. Intravenous and Oral Steroids Are Associated with Similar Outcomes in Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 45. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/intravenous-and-oral-steroids-are-associated-with-similar-outcomes-in-acute-exacerbations-of-chronic-obstructive-pulmonary-disease/. Accessed April 10, 2020.