Corticosteroids for acute and subacute cough following respiratory tract infection: a systematic review

Oral prednisolone for acute lower respiratory tract infection in clinically unrecognised asthma: an exploratory analysis of the Oral Steroids for Acute Cough (OSAC) randomised controlled trial

Background

Acute lower respiratory tract infection (ALRTI) is often treated in primary care with antibiotics. The recent Oral Steroids for Acute Cough (OSAC) randomised controlled trial (RCT) showed corticosteroids were not an effective alternative in adults without a diagnosis of asthma with ALRTI.

Aim

To investigate if corticosteroids are beneficial for ALRTI in patients with unrecognised asthma.

Design & setting

An exploratory analysis was undertaken of the primary care OSAC trial.

Method

A subgroup analysis was performed in patients who responded ‘yes’ to the following International Primary Care Airways Group (IPCAG) question: did you have wheeze and/or at least two of nocturnal cough or chest tightness or dyspnoea in the past year. Sensitivity analyses were carried out on those who answered ‘yes’ to wheeze and at least two of the nocturnal symptoms. The primary outcomes were as follows: duration of cough (0–28 days, minimum clinically important difference [MCID] of 3.79 days) and mean symptom severity score (range 0–6; MCID 1.66 units).

Results

In total, 40 (10%) patients were included in the main analysis: mean age 49 years (standard deviation [SD] = 17.9), 52% male. Median cough duration was 3 days in both prednisolone (interquartile range [IQR] = 2–6 days) and placebo (IQR = 1–6 days) groups (adjusted hazard ratio [HR] = 1.10; 95% confidence interval [CI] = 0.47 to 2.54; P = 0.83), equating to 0.24 days longer in the prednisolone group (95% CI = 1.23 days shorter to 2.88 days longer). Mean symptom severity difference was –0.14 (95% CI = –0.78 to 0.49; P=0.65) comparing prednisolone with placebo. Similar findings were found in the sensitivity analysis.

Conclusion

No evidence was found to support the use of corticosteroids for ALRTI in patients with clinically unrecognised asthma. Clinicians should not use the IPCAG questions to target oral corticosteroid treatment in patients with ALRTI.

Oral corticosteroids for post-infectious cough in adults: study protocol for a double-blind randomized placebo-controlled trial in Swiss family practices (OSPIC trial)

BACKGROUND

Cough is a common reason for patients to visit general practices. So-called post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection. It can be disabling in daily activities, with substantial impact on physical and psychosocial health, leading to impaired quality of life and increased health care costs. Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. A systematic review and meta-analysis of randomized clinical trials (RCT) assessing patient-relevant benefits and potential harms of available treatments identified six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, gelatine). No RCT found clear patient-relevant benefits and most had an unclear or high risk of bias. Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases for which there is strong evidence that oral corticosteroids provide patient-relevant benefit without relevant harm. We therefore plan to conduct the first RCT evaluating the effectiveness of oral corticosteroids for post-infectious cough.

METHODS

We are conducting a triple-blinded randomized-controlled and multicentred superiority trial in primary health care practices in Switzerland. We will include 204 adult patients who consult their general practitioner (GP) for a cough lasting 3 to 8 weeks following an upper respiratory tract infection. Participants will be randomly allocated to either the 5-day treatment with oral corticosteroids or placebo. The primary outcome is cough-related quality of life assessed by the Leicester Cough Questionnaire score 14 days after randomization. Secondary outcomes include cough-related quality of life at several time points, overall cessation of cough and adverse events.

DISCUSSION

This RCT will provide evidence on whether oral corticosteroids are beneficial and safe in patients with post-infectious cough. Results can have a substantial impact on the well-being and management of these patients in Switzerland and beyond. An evidence-based treatment for this condition may reduce re-consultations with GPs and spending for antitussive drugs, thus possibly having an impact on health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04232449 . Prospectively registered on 18 January 2020.

Use of antibiotics and asthma medication for acute lower respiratory tract infections in people with and without asthma: retrospective cohort study

Background

Antibiotics are overused in patients with acute lower respiratory tract infections (ALRTIs), but less is known about their use in patients with asthma, or the use of asthma medication for ALRTI in patients without asthma. Our aim was to describe the frequency, variation and drivers in antibiotic and asthma medication prescribing for ALRTI in adults with and without asthma in primary care.

Methods

A retrospective cohort analysis of patients aged ≥12 years, diagnosed with an ALRTI in primary care in 2014–15 was conducted using data from the Clinical Practice Research Datalink. Current asthma status, asthma medication and oral antibiotic use within 3 days of ALRTI infection was determined. Treatment frequency was calculated by asthma status. Mixed-effect regression models were used to explore between-practice variation and treatment determinants.

Results

There were 127,976 ALRTIs reported among 110,418 patients during the study period, of whom 17,952 (16%) had asthma. Respectively, 81 and 79% of patients with and without asthma received antibiotics, and 41 and 15% asthma medication. There were significant differences in between-practice prescribing for all treatments, with greatest differences seen for oral steroids (odds ratio (OR) 18; 95% CI 7–82 and OR = 94; 33–363, with and without asthma) and asthma medication only (OR 7; 4–18 and OR = 17; 10–33, with and without asthma).

Independent predictors of antibiotic prescribing among patients with asthma included fewer previous ALRTI presentations (≥2 vs. 0 previous ALRTI: OR = 0.25; 0.16–0.39), higher practice (OR = 1.47; 1.35–1.60 per SD) and prior antibiotic prescribing (3+ vs. 1 prescriptions OR = 1.28; 1.04–1.57) and concurrent asthma medication (OR = 1.44; 1.32–1.57). Independent predictors of asthma medication in patients without asthma included higher prior asthma medication prescribing (≥7 vs. 0 prescriptions OR = 2.31; 1.83–2.91) and concurrent antibiotic prescribing (OR = 3.59; 3.22–4.01).

Conclusion

Findings from the study indicate that antibiotics are over-used for ALRTI, irrespective of asthma status, and asthma medication is over-used in patients without asthma, with between-practice variation suggesting considerable clinical uncertainty. Further research is urgently needed to clarify the role of these medications for ALRTI.

Effectiveness of antitussives, anticholinergics or honey versus usual care in adults with uncomplicated acute bronchitis: a study protocol of an open randomised clinical trial in primary care

INTRODUCTION

Despite the frequent use of therapies in acute bronchitis, the evidence of their benefit is lacking, since only a few clinical trials have been published, with low sample sizes, poor methodological quality and mainly in children. The objective of this study is to compare the effectiveness of three symptomatic therapies (dextromethorphan, ipratropium or honey) associated with usual care and the usual care in adults with acute bronchitis.

METHODS AND ANALYSIS

This will be a multicentre, pragmatic, parallel group, open randomised trial. Patients aged 18 or over with uncomplicated acute bronchitis, with cough for less than 3 weeks as the main symptom, scoring ≥4 in either daytime or nocturnal cough on a 7-point Likert scale, will be randomised to one of the following four groups: usual care, dextromethorphan 30 mg three times a day, ipratropium bromide inhaler 20 µg two puffs three times a day or honey 30 mg (a spoonful) three times a day, all taken for up to 14 days. The exclusion criteria will be pneumonia, criteria for hospital admission, pregnancy or lactation, concomitant pulmonary disease, associated significant comorbidity, allergy, intolerance or contraindication to any of the study drugs or admitted to a long-term residence.

SAMPLE

668 patients. The primary outcome will be the number of days with moderate-to-severe cough. All patients will be given a paper-based symptom diary to be self-administered. A second visit will be scheduled at day 2 or 3 for assessing evolution, with two more visits at days 15 and 29 for clinical assessment, evaluation of adverse effects, re-attendance and complications. Patients still with symptoms at day 29 will be called 6 weeks after the baseline visit.

ETHICS AND DISSEMINATION

The study has been approved by the Ethical Board of IDIAP Jordi Gol (reference number: AC18/002). The findings of this trial will be disseminated through research conferences and peer-review journals.

TRIAL REGISTRATION NUMBER

NCT03738917; Pre-results.

Acute cough in Italian children: parents' beliefs, approach to treatment, and the family impact

BACKGROUND

Acute cough is the most common symptom among children in primary care, but the impact of cough episodes was never investigated in Italian families.

METHODS

A cross-sectional telephone survey was conducted on a representative sample of Italian families, randomly selected from general population; a specific and validated questionnaire was used.

RESULTS

The sample (604 calls) was uniform by geographical distribution, and by children age and gender. Mean cough episode was 3.1/year, they were short lasting (only 4.7% > 2 weeks). Independent predictors of children cough episodes were parents' active smoking habit and work (p < 0.05). The mean nursery/school absenteeism was mostly < 7 days, but of a 7-15-day duration in near 30% of cases. The pediatrician was contacted immediately only by 25% of parents and a second consultation (mostly a lung physician) usually occurred after 2-3 weeks of cough. Meanwhile, home/pharmacist suggested remedies were adopted in 50-70% of cases. Usual prescriptions were mucolytics (85.8%), antitussive agents (55.6%), non-steroideal anti-inflammatory drugs (33.8%), antibiotics (regularly or episodically 80%), and corticosteroids (systemic steroids in less than 50%, but via aerosol in more than 80% of cases). Moreover, pediatricians claimed to use homeopathic drugs regularly or episodically in almost 50%. The respondents' willingness to spend out-of-pocket for an "effective remedy" against cough was of € 20 (>€ 30 in 18.4% of cases).

CONCLUSIONS

Parents' actions against cough episodes were variable, depending on their beliefs, smoking habit, and occupational status. The parents' perceived efficacy of usual prescriptions is poor, and their willingness to pay out-of-pocket for an "effective remedy" against cough is high. The interest for alternative treatments is not negligible in these circumstances.

Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials

BACKGROUND

Subacute cough following a non-specific viral infection lasting 3-8 weeks is common. However, despite many treatment options there are no systematic reviews evaluating these.

AIM

To provide a systematic overview of treatment options and outcomes evaluated in randomised clinical trials (RCTs).

DESIGN AND SETTING

Systematic review and meta-analyses assessing the overall effects of any treatment for subacute cough.

METHOD

The authors systematically searched PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (last search March 2017) for RCTs in adult patients with subacute cough. The authors considered trials evaluating any outcome of any drug or non-drug treatments, apart from traditional Chinese and Asian medicines. They combined treatment effects on cough-related outcomes in random effects meta-analyses.

RESULTS

Six eligible RCTs including 724 patients were identified. These assessed montelukast, salbutamol plus ipratropium bromide, gelatine, fluticasone propionate, budesonide, and nociception opioid 1 receptor agonist and codeine. Five studies reported effects on various cough severity scores at various timepoints. No treatment option was associated with a clear benefit on cough recovery or other patient-relevant outcomes in any of the studies or in meta-analyses for cough outcomes at 14 days and 28 days. Reported adverse events were rather mild and reported for 14% of patients across all treatments.

CONCLUSION

Evidence on treatment options for subacute cough is weak. There is no treatment showing clear patient-relevant benefits in clinical trials.

Effect of Oral Prednisolone on Symptom Duration and Severity in Nonasthmatic Adults With Acute Lower Respiratory Tract Infection: A Randomized Clinical Trial

IMPORTANCE

Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence.

OBJECTIVE

To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, placebo-controlled, randomized trial (July 2013 to final follow-up October 2014) conducted in 54 family practices in England among 401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years.

INTERVENTIONS

Two 20-mg prednisolone tablets (n = 199) or matched placebo (n = 202) once daily for 5 days.

MAIN OUTCOMES AND MEASURES

The primary outcomes were duration of moderately bad or worse cough (0 to 28 days; minimal clinically important difference, 3.79 days) and mean severity of symptoms on days 2 to 4 (scored from 0 [not affected] to 6 [as bad as it could be]; minimal clinically important difference, 1.66 units). Secondary outcomes were duration and severity of acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, and adverse events.

RESULTS

Among 401 randomized patients, 2 withdrew immediately after randomization, and 1 duplicate patient was identified. Among the 398 patients with baseline data (mean age, 47 [SD, 16.0] years; 63% women; 17% smokers; 77% phlegm; 70% shortness of breath; 47% wheezing; 46% chest pain; 42% abnormal peak flow), 334 (84%) provided cough duration and 369 (93%) symptom severity data. Median cough duration was 5 days (interquartile range [IQR], 3-8 days) in the prednisolone group and 5 days (IQR, 3-10 days) in the placebo group (adjusted hazard ratio, 1.11; 95% CI, 0.89-1.39; P = .36 at an α = .05). Mean symptom severity was 1.99 points in the prednisolone group and 2.16 points in the placebo group (adjusted difference, -0.20; 95% CI, -0.40 to 0.00; P = .05 at an α = .001). No significant treatment effects were observed for duration or severity of other acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, or nonserious adverse events. There were no serious adverse events.

CONCLUSIONS AND RELEVANCE

Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity.

TRIAL REGISTRATION

ISRCTN.com Identifier: ISRCTN57309858.

Clinical perspective - cough: an unmet need

Cough is among the most common complaints for which individuals worldwide seek medical attention. The vast majority of cases of acute cough (<3 weeks duration) are due to acute viral upper respiratory tract infection (URI) (common cold). Fortunately, acute cough is typically transient and self-limited. However, should severe and/or persistent acute cough require pharmacological treatment, satisfactory therapeutic options are scarce. Narcotic antitussives are limited by unacceptable side effects at therapeutic doses, and most over-the-counter (OTC) remedies are not supported by adequate clinical trials. The goal in chronic cough (>8 weeks duration) is to meticulously evaluate and treat all potential underlying etiologies. Despite thorough investigation, a significant minority of patients will suffer refractory, unexplained cough. For this challenging population, safe, effective, non-narcotic antitussive therapies are desperately needed.

Can oral corticosteroids reduce the severity or duration of an acute cough, and the associated National Health Service and societal costs, in adults presenting to primary care? Study protocol for a randomised controlled trial

BACKGROUND

Acute lower respiratory tract infection (LRTI) is one of the most common conditions managed internationally and is costly to health services and patients. Despite good evidence that antibiotics are not effective for improving the symptoms of uncomplicated LRTI, they are widely prescribed, contributing to antimicrobial resistance. Many of the symptoms observed in LRTI are mediated by inflammatory processes also observed in exacerbations of asthma, for which there is strong evidence of corticosteroid effectiveness. The primary aim of the OSAC (Oral Steroids for Acute Cough) Trial is to determine whether oral prednisolone (40 mg daily for 5 days) can reduce the duration of moderately bad (or worse) cough and the severity of all its associated symptoms on days 2 to 4 post-randomisation (day 1 is trial entry) by at least 20% in adults ≥18 years with acute LRTI presenting to primary care.

METHODS/DESIGN

OSAC is a two-arm, multi-centre, placebo-controlled, randomised superiority trial. The target sample size is 436 patients, which allows for a 20% dropout rate. Patients will be recruited from primary care sites (General Practitioner surgeries) across England and followed up until symptom resolution. The two primary clinical outcomes are the duration of moderately bad (or worse) cough, and the severity of all its associated symptoms on days 2 to 4 post-randomisation. Secondary outcomes include: antibiotic consumption; symptom burden; adverse events; participant satisfaction with treatment and intention to consult for future similar illnesses. A parallel economic evaluation will investigate the cost-effectiveness of the intervention.

DISCUSSION

Results from the OSAC trial will increase knowledge regarding the clinical and cost-effectiveness of corticosteroids for LRTI, and will establish the potential of a new treatment option that could substantially improve patient health. We have chosen a relatively high 'efficacy dose' as this will enable us to decide on the potential for further research into lower dose oral and/or inhaled corticosteroids. This trial will also contribute to a growing body of research investigating the natural course of this very common illness, as well as the effects of steroids on the undesirable inflammatory symptoms associated with infection.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57309858 (31 January 2013).

Prevalence of inappropriate prescribing of inhaled corticosteroids for respiratory tract infections in the Netherlands: a retrospective cohort study

BACKGROUND

Inhaled corticosteroids (ICS) are recommended in prevailing guidelines for use in patients with persistent asthma or moderate-to-severe chronic obstructive pulmonary disease (COPD) and recurrent exacerbations. Recent data from Australia showed that 44% of patients with a single ICS dispensing and without other respiratory inhalation medications ('one-off ICS') were co-dispensed oral antibiotics. Evidence of the merit of ICS for treating respiratory infections in subjects without asthma or COPD is lacking.

AIMS

The aims of the study were to describe the rate of one-off ICS dispensing in combination with oral antibiotics in subjects without chronic respiratory conditions in the Netherlands, and to compare this with the rate of one-off ICS dispensing in combination with oral antibiotics as reported earlier from Australia.

METHODS

Dispensing data were obtained from the Dutch Foundation of Pharmaceutical Statistics. Additional information was available on patients' age, sex and prescriber. Patients with any ICS dispensing in 2011 were selected.

RESULTS

Data were available from 1,725 Dutch community pharmacies (88%). Of 845,068 ICS users in 2011, 10% were dispensed one-off ICS, among which 13% had oral antibiotics co-dispensed. These ICS were mainly prescribed by general practitioners, mostly during winter months, for elderly persons, after high dosages of oral corticosteroids, and in single-inhaler combinations with a long-acting β2-agonist. The extrapolated total annual expense for this ICS use was € 555,000.

CONCLUSION

In the Netherlands one-off ICS dispensing in combination with oral antibiotics in subjects without chronic respiratory conditions was considerably lower than in Australia.

Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial

OBJECTIVE

To evaluate the efficacy of oral anti-inflammatory or antibiotic treatment compared with placebo in the resolution of cough in patients with uncomplicated acute bronchitis and discoloured sputum.

DESIGN

Multicentre, parallel, single blinded placebo controlled, randomised clinical trial.

SETTING

Nine primary care centres in Spain.

PARTICIPANTS

Adults aged 18 to 70 presenting symptoms associated with respiratory tract infection of less than one week's duration, with cough as the predominant symptom, the presence of discoloured sputum, and at least one other symptom of lower respiratory tract infection (dyspnoea, wheezing, chest discomfort, or chest pain).

INTERVENTIONS

Patients were randomised to receive either ibuprofen 600 mg three times daily, amoxicillin-clavulanic acid 500 mg/125 mg three times daily, or placebo three times daily for 10 days. The duration of symptoms was measured with a diary card.

MAIN OUTCOME MEASURE

Number of days with frequent cough after the randomisation visit.

RESULTS

416 participants were randomised (136 to ibuprofen, 137 to antibiotic, and 143 to placebo) and 390 returned their symptom diaries fully completed. The median number of days with frequent cough was slightly lower among patients assigned to ibuprofen (9 days, 95% confidence interval 8 to 10 days) compared with those receiving amoxicillin-clavulanic acid (11 days, 10 to 12 days) or placebo (11 days, 8 to 14 days), albeit without statistically significant differences. Neither amoxicillin-clavulanic acid nor ibuprofen increased the probability of cough resolution (hazard ratio 1.03, 95% confidence interval 0.78 to 1.35 and 1.23, 0.93 to 1.61, respectively) compared with placebo. Adverse events were observed in 27 patients, and were more common in the antibiotic arm (12%) than ibuprofen or placebo arms (5% and 3%, respectively; P<0.01).

CONCLUSION

No significant differences were observed in the number of days with cough between patients with uncomplicated acute bronchitis and discoloured sputum treated with ibuprofen, amoxicillin-clavulanic acid, or placebo.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07852892.