Is There a Role for Systemic Corticosteroids in the Management of Stable Chronic Obstructive Pulmonary Disease?
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Is There a Role for Systemic Corticosteroids in the Management of Stable Chronic Obstructive Pulmonary Disease? Richard Wood-Baker Royal Hobart Hospital & University of Tasmania, Hobart, Tasmania, Australia
Abstract
COPD, encompassing both chronic bronchitis and emphysema, usually results from exposure to tobacco smoke. Smoking causes infiltration of the airways with leukocytes, an imbalance between proteases and their naturally occurring inhibitors and local cytokine secretion in the lung, which leads to airway inflammation and alveolar destruction. Corticosteroids have a range of anti-inflammatory actions, particularly inhibition of cytokine secretion, which suggests that they may be effective in COPD. However, data from the highest quality studies available do not show any evidence of significant improvement in symptoms of patients with COPD treated with systemic corticosteroids. A meta-analysis found that about 10% of patients with stable COPD showed an improvement in lung function following treatment with short-term systemic corticosteroids compared with placebo. Exercise capacity in patients with COPD was evaluated in four studies, only one of which found a significant improvement with oral corticosteroids compared with placebo. Long-term systemic corticosteroid treatment in patients with stable COPD has not been found to alter the rate of decline in FEV1. Although systemic corticosteroids are associated with a range of adverse effects, the data do not allow precise quantification of their contribution to morbidity. However, studies show an increased risk of osteoporosis in COPD. Recent studies have also found an association between oral corticosteroid administration and mortality in patients with stable COPD, but it is not clear if this is a cause and effect relationship. Current data do not support long-term administration of systemic corticosteroids to all patients with stable COPD. Results of studies suggest that short-term oral corticosteroid administration may identify a sub-population of patients with COPD who may benefit through a reduction in the decline in FEV1 and better control of symptoms by long-term administration of inhaled corticosteroids; these findings need to be tested by further research.
This article is a narrative review of systemic corticosteroids (oral or intravenous) in the management of stable COPD. It is not as robust as a systematic review in its approach to literature searching, appraisal, or statistical analysis.[1] As a systematic review of the topic has not been performed to date, lower levels of evidence[2] on effect will have to be accepted to guide management. A relevant protocol is registered with the Cochrane Collaboration,[3] and it is likely that more robust evidence will emerge in the future. This article is based on a search of Medline and Embase
using the keywords adrenal cortex hormones, corticosteroids, prednisone, prednisolone, cortisone, cortisone acetate, methyl prednisolone and pulmonar
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