Is there an optimal corticosteroid regimen for the management of an acute exacerbation of chronic obstructive pulmonary disease?

Dex-CSDH randomised, placebo-controlled trial of dexamethasone for chronic subdural haematoma: report of the internal pilot phase

The Dex-CSDH trial is a randomised, double-blind, placebo-controlled trial of dexamethasone for patients with a symptomatic chronic subdural haematoma. The trial commenced with an internal pilot, whose primary objective was to assess the feasibility of multi-centre recruitment. Primary outcome data collection and safety were also assessed, whilst maintaining blinding. We aimed to recruit 100 patients from United Kingdom Neurosurgical Units within 12 months. Trial participants were randomised to a 2-week course of dexamethasone or placebo in addition to receiving standard care (which could include surgery). The primary outcome measure of the trial is the modified Rankin Scale at 6 months. This pilot recruited ahead of target; 100 patients were recruited within nine months of commencement. 47% of screened patients consented to recruitment. The primary outcome measure was collected in 98% of patients. No safety concerns were raised by the independent data monitoring and ethics committee and only five patients were withdrawn from drug treatment. Pilot trial data can inform on the design and resource provision for substantive trials. This internal pilot was successful in determining recruitment feasibility. Excellent follow-up rates were achieved and exploratory outcome measures were added to increase the scientific value of the trial.

Evaluation of Systemic Corticosteroids in Patients With an Acute Exacerbation of COPD and a Diagnosis of Pneumonia

Background: Chronic obstructive pulmonary disease (COPD) and pneumonia are leading causes of morbidity and mortality and are frequently comorbid. Studies of systemic corticosteroids in pneumonia have shown conflicting outcomes, whereas studies in acute exacerbations of COPD (AECOPD) have shown significant benefits. No studies have evaluated systemic corticosteroids in patients with both an AECOPD and pneumonia. Purpose: To evaluate the use of systemic corticosteroids in patients with both an AECOPD and pneumonia. Patients and Methods: Patients with a diagnosis of both COPD or obstructive chronic bronchitis with exacerbation and pneumonia admitted to the University of Colorado Hospital between July 1, 2012 and May 20, 2016 were retrospectively evaluated. Patients who received systemic corticosteroids were compared to those that did not. The primary outcome was length of hospital stay (LOHS). Secondary outcomes were in-hospital treatment failure, a composite of intensive care unit (ICU) admission, ventilation, and escalation of steroid therapy, 30-day AECOPD or pneumonia readmission, and 30-day mortality. Results: A total of 138 patients were included-- 89 in the steroid group and 49 in the non-steroid group. No significant differences in baseline characteristic were noted. No difference was seen in mean LOHS (4.7±3.2 versus 4.2±2.1 days, p=0.27), in-hospital treatment failure (7% versus 4%, p=0.72), 30-day readmission or 30-day mortality between the steroid and non-steroid groups, respectively. There was a difference in mean LOHS for patients with severe pneumonia between the steroid and non-steroid groups (6.0±4.0 versus 4.3±1.8; p=0.03). Conclusions: This study suggests that systemic corticosteroids may not provide a clinical benefit to patients with an AECOPD and pneumonia.

Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insufficiency (CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit (ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group (n=32) and a control group (n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone (150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers of inflammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value <0.05 was considered statistically significant.

RESULTS

Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4%. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI (23.8% vs. 8.7%, P<0.01). Kaplan-Meier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group (P<0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group (18.2±9.5 vs. 25.8±4.1, P<0.05). Treatment with low-dose glucocorticoid obviously decreased the markers of infection and inflammation (P<0.01), such as C-reactive protein (13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α (26.1±16.2 μg/L vs. 17.5±11.7 μg/L for the control group; 25.0±14.8 μg/L vs. 10.4±7.8 μg/L for the treatment group) and procalcitonin (3.88 μg/L vs. 2.03 μg/L for the control group; 3.77 μg/L vs. 1.26 μg/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group (P<0.01).

CONCLUSION

The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers of infection and inflammation.

Ergogenic and metabolic effects of oral glucocorticoid intake during repeated bouts of high-intensity exercise

All systemically administered glucocorticoids (GC) are prohibited in-competition, because of the potential ergogenic effects. Although short-term GC intake has been shown to improve performance during submaximal exercise, literature on its impact during brief intense exercise appears to be very scant. The purpose of this study was to examine the ergogenic and metabolic effects of prednisone during repeated bouts of high-intensity exercise. In a double-blind randomized protocol, ten recreational male athletes followed two 1-week treatments (Cor: prednisone, 60mg/day or Pla: placebo). At the end of each treatment, they hopped on their dominant leg for 30s three times consecutively and then hopped until exhaustion, with intervals of 5min of passive recovery. Blood and saliva samples were collected at rest and 3min after each exercise bout to determine the lactate, interleukin-6, interleukin-10, TNF-alpha, DHEA and testosterone values. The absolute peak force of the dominant leg was significantly increased by Cor but only during the first 30-s hopping bout (p<0.05), whereas time to exhaustion was not significantly changed after Cor treatment vs Pla (Pla: 119.9±24.7; Cor: 123.1±29.5s). Cor intake lowered basal and end-exercise plasma interleukin-6 and saliva DHEA (p<0.01) and increased interleukin-10 (p<0.01), whereas no significant change was found in blood lactate and TNF-alpha or saliva testosterone between Pla and Cor. According to these data, short-term glucocorticoid intake did not improve endurance performance during repeated bouts of high-intensity exercise, despite the significant initial increase in absolute peak force and anti-inflammatory effect.

Chronic Obstructive Pulmonary Disease: Inpatient Management

This article outlines the management of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD), which are common in the course of chronic COPD and are associated with substantial morbidity. There are numerous guidelines, but literature suggests that there is substantial variation in care in patients with acute exacerbations of COPD. Key components of acute therapy for most patients include oral steroids, antibiotics, nebulizers, oxygen, and early consideration of noninvasive ventilation. Adjuvant components of care include venous thromboembolism prophylaxis, appropriate immunizations, counseling for smoking cessation, and consideration of pulmonary rehabilitation.

Pioglitazone decreases hepatitis C viral load in overweight, treatment naïve, genotype 4 infected-patients: a pilot study

BACKGROUND

Insulin resistance (IR) is induced by chronic hepatitis C virus (HCV) genotypes 1 and 4 infections. It is not known whether drugs that affect IR such as Pioglitazone and Prednisone also affect serum HCV RNA titers independently of PEG-Interferon-α2/ribavirin treatment. The primary aim was to assess whether Pioglitazone by improving IR and/or inflammation decreases HCV viral load independently of standard of care HCV treatment. A secondary aim was to assess whether Prednisone, a drug that induces insulin resistance and stimulates HCV viral entry and replication in replicon culture systems, increases HCV viral load in this population.

METHODOLOGY/PRINCIPAL FINDINGS

We designed a two-arm, parallel Pilot Study of overweight, treatment naïve genotype 4 HCV-infected patients at a public referral Liver Clinic in Giza, Egypt. The subjects received Pioglitazone (30 mg/day for 14 days) or Prednisone (40 mg/day for 4 days) in a randomized fashion, but the two arms can be considered independent pilot studies. Only changes from baseline within each arm were assessed and no contrasts of the interventions were made, as this was not an aim of the study. Among 105 consecutive HCV genotype 4 patients, 39 were enrolled based on the optimal sample size and power analysis according to the CONSORT statement; 20 to the Pioglitazone group and 19 to the Prednisone group. Pioglitazone was effective in decreasing serum HCV RNA at day-14 (n = 10; difference of means = 205,618 IU/ml; 95% CI 26,600 to 384,600; P<0.001). Although Prednisone did increase serum HCV RNA at day-4 (n = 10; change from baseline = -42,786 IU/ml; 95% CI -85,500 to -15,700; P = 0.049), the log(10) HCV RNA titers were statistically not different from baseline day-0.

CONCLUSION/SIGNIFICANCE

This is the first documentation that Pioglitazone decreases the serum HCV RNA titers independently of PEG-Interferon-α2/ribavirin treatment. The novel findings of our Study provide the foundation for basic and clinical investigations on the molecular mechanisms responsible for the Pioglitazone-induced decrease in HCV genotype 4 RNA titers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01157975.

Propensity score models in observational comparative effectiveness studies: cornerstone of design or statistical afterthought?

Propensity score models are increasingly used in observational comparative effectiveness studies to reduce confounding by covariates that are associated with both a study outcome and treatment choice. Any such potentially confounding covariate will bias estimation of the effect of treatment on the outcome, unless the distribution of that covariate is well-balanced between treatment and control groups. Constructing a subsample of treated and control subjects who are matched on estimated propensity scores is a means of achieving such balance for covariates that are included in the propensity score model. If, during study design, investigators assemble a comprehensive inventory of known and suspected potentially confounding covariates, examination of how well this inventory is covered by the chosen dataset yields an assessment of the extent of bias reduction that is possible by matching on estimated propensity scores. These considerations are explored by examining the designs of three recently published comparative effectiveness studies.

Effect of a 14-day course of systemic corticosteroids on the hypothalamic-pituitary-adrenal-axis in patients with acute exacerbation of chronic obstructive pulmonary disease

Background

As supra-physiological intake of corticosteroids is a well known risk factor for the development of adrenal insufficiency, we investigated the function of the hypothalamic-pituitary-adrenal (HPA) axis during a 14-day course of systemic corticosteroids in patients with acute exacerbation of chronic obstructive pulmonary disease using clinical and laboratory measures.

Methods

A systematic clinical and laboratory assessment including measurement of basal cortisol levels and the response to low dose (1 μg) ACTH stimulation was performed in nine patients before, on the first and the last day of treatment, as well as 2, 7 and 21 days after corticosteroid withdrawal.

Results

At baseline, all nine patients had normal responses to 1 μg ACTH. On the first day of steroid treatment, 78% had a blunted peak cortisol response. This percentage increased to 89% after 14 days of steroid treatment. 78%, 33% and 33% of the patients had a blunted cortisol response to ACTH 2, 7, and 21 days after corticosteroid withdrawal, respectively. ROC curve analysis revealed that only basal cortisol concentrations (AUC 0.89), but not ACTH concentrations (AUC 0.49) or clinical signs (AUC 0.47) were predictive of an impaired function of the HPA axis. Basal cortisol levels of > 400 and < 150 nmol/l were 96% and 100% sensitive for a normal or pathological response to the ACTH stimulation test, respectively.

Conclusion

Immediate and prolonged suppression of the HPA axis is a common finding in otherwise asymptomatic patients undergoing systemic steroid treatment for acute exacerbation of chronic obstructive pulmonary disease and can reliably be assessed with the low-dose ACTH test.

Effects of short-term prednisolone intake during submaximal exercise

PURPOSE

To examine the prednisolone's ergogenic and metabolic effects during submaximal exercise.

METHODS

Ten recreational male athletes completed two cycling trials at 70-75% peak O2 consumption until exhaustion after either placebo (Pla, lactose) or oral prednisolone (Pred, 60 mg.d(-1) for 1 wk) treatment, according to a double-blind and randomized protocol. Blood samples were collected at rest and during exercise and recovery to determine ACTH, growth hormone (GH), prolactin (PRL), DHEA, insulin, blood glucose, and blood lactate values.

RESULTS

Time of cycling was significantly increased after chronic Pred treatment (Pred: 74.5+/-9.5 min; Pla: 46.1+/-3.3 min, P<0.01). Pred intake significantly lowered basal, exercise, and recovery ACTH, DHEA, and PRL concentrations, whereas GH concentrations were significantly lowered by Pred after 30 min of exercise. Blood glucose and insulin were significantly (P<0.05) increased by Pred during the whole experiment and until 30 min of exercise. Blood lactate concentrations were higher after Pred versus Pla at 10 min of exercise until 10 min of recovery (P<0.05).

CONCLUSION

From these data, short-term Pred intake did seem to significantly improve performance during submaximal exercise, with concomitant alterations in hormonal and metabolic responses. Further studies will be necessary to elucidate the mechanisms of these hormonal and metabolic changes, and to determine whether the changes may be associated with the marked performance improvement obtained.