Chronic Obstructive Pulmonary Disease - Article Example

Association of Corticosteroid Dose and Route of Administration with Risk of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease JAMA. 2010;303(23):2359-2367 Peter K. Lindenauer; Penelope S. Pekow; Maureen C. Lahti; et al. Name Date Background Introduction Two different conditions emphysema and chronic bronchitis are joined together and given the name of Chronic Obstructive Pulmonary Disease.2 The major leading cause of Chronic Obstructive Pulmonary Disease is cigarette smoking although this disease has also been reported in non smokers.1,2,5 The main signs and symptoms of Chronic Obstructive Pulmonary Disease include cough which is productive that is with sputum as well as breathlessness and wheezing.2 The main tests which should be performed for the diagnosis of this condition include spirometry, bronchoscopy, X- rays of the chest and exercise tolerance test.5 Prevention from further damage involves advising the patient to quit smoking and to avoid exposure to dust and other environmental pollutants as early as possible.1,2,5 General Information1,3,5 Corticosteroids are the treatment employed for controlling moderate to severe chronic obstructive pulmonary disease. It is used mainly in combination with bronchodilators which include anticholinergics for example ipratropium and tiotropium. In severe cases, bronchodilators, corticosteroids along with oxygen therapy are used. Corticosteroids are mainly used in the form of inhalants but they may also be given orally and through the intravenous route. Mechanism of Action1,3 Corticosteroids act as anti-inflammatory agents. They act by reducing and inhibiting the eosinophils, macrophages as well as T lymphocytes. The edema that occurs due to inflammation is alleviated as well as the leakage of capillaries is reduced. It works towards reducing the reaction of the smooth muscles of the airways to foreign agents. Adverse Effects1,3 Oropharyngeal Candidiasis. Hoarseness of voice. May enhance the risk of osteoporosis and cataract. Reduction in the activity of the adrenal gland. The Study4 Purpose of the study To evaluate the differences in the treatment effect observed by administering steroids to patients suffering from acute exacerbation of chronic obstructive pulmonary disease either at low dosage by the oral route or at high dosage by the intravenous route. GENERAL STUDY OVERVIEW Study Design Retrospective Cohort study. Administration of corticosteroids to patients for two consecutive days following admission to the hospital. Data Sources Data was only collected from the hospitals under the Premier Incorporated’s Perspective. This data was not only restricted to the discharge files of patient, but rather the Premier Incorporated Perspective maintained better patient records with the therapies plus the diagnostic tests and all other aspects of patient information. METHODS Inclusion criteria Patients admitted from the period of January 1 2006 to December 1 2007. The age of patients was 40 years or above. The patients were suffering from mainly acute exacerbation of chronic obstructive pulmonary disease or emphysema or failure of the respiratory system along with either COPD or emphysema. The patients were mainly given corticosteroids systemically for the 2 days following admission. Exclusion Criteria If the dosage of the corticosteroids lied outside the normal range of treatment. Patients put on mechanical ventilation immediately following admission. If the COPD was associated with complications which included pneumonia or pulmonary embolism. Patients who were discharged within one day from the hospital. The patients were not treated with corticosteroids during either of the first two days of their treatment. The dates of admission were not clarified. Recruitment Patients were screened from 414 hospitals in the United States which were participants of the Premier Incorporated’s Perspective and a total of 78985 patients were chosen. Intervention The route as well as the amount of corticosteroids administered was determined from the records. Two groups were formulated which included patients who were treated on low doses of corticosteroids which were administered orally as well as patients who were treated with high doses of corticosteroids which was given intravenously. The low dose oral therapy was classified as an oral dosage in between the range of 20 to 80 mg of prednisone. The high intravenous dose therapy was classified as 120 to 800 mg of prednisone. Primary Outcomes Irresponsiveness of the patient to therapy which resulted in putting the patient on mechanical ventilation following the first two days of therapy. The death of the patient in the hospital. The patient reported to the hospital again with the diagnosis of COPD within a month after the discharge. Secondary Outcomes The number of days that the patient stayed at the hospital. The total expenses at the hospital. RESULTS Statistics 71628 patients out of the 79985 patients had COPD as their major diagnosis. 8537 were suffering from failure of the respiratory system. 61 percent of the patients were females. Whites formed 73 percent of the total number. The most common witnessed comorbidities included hypertension, diabetes and depression. 941 patients failed to respond to therapy within the first two days and had to be eventually put on mechanical ventilation. The number of fatalities was 1080. 6911 patients reported to the hospital against with COPD within the period of a month. The Kruskal-Wallis tests were put into use for checking the relationship of the treatment with the primary and secondary outcomes of the patient. After the high dose intravenous route, the number of deaths were 1.4% (95% confidence interval [CI], 1.3%-1.5%) and the patients who responded with primary outcomes were 10.9% (95% CI, 10.7%-11.1%) Whereas for the oral low dose corticosteroids, the number of deaths were 1.0% (95% CI, 0.7%-1.2%) and patients presenting with primary outcomes were 10.3% (95% CI, 9.5%-11.0%). According to the multivariable regression model, the risk of the patient not responding to treatment via the oral route was less than that via the intravenous route that is (odds ratio [OR], 0.93; 95% CI, 0.84-1.02). This model was to analyze the effect of the route chosen for the corticosteroids with the primary and secondary outcomes of the patient. Logit-link models served the purpose of analyzing the failed response to treatment. Outcomes The patients who were on low dose oral therapy had a lower chance of experiencing failure of the therapy. The patients on low dose oral therapy also had lower hospital stay time. The costs of these patients were also lower. The risk associated with failure of treatment between the high dose intravenous therapy as well as the low dose oral therapy does not show much difference. STUDY CONCLUSION AUTHORS CONCLUSION High dose intravenous therapy does not provide any major benefits which are superior to the results of treatment with low dose corticosteroids administered orally. Rather the intravenous therapy is associated with pain and carries a risk of infection and higher costs in comparison to the oral low dose corticosteroid therapy. MY CONCLUSION The research does provide strong support about the authors conclusion that low dose orally administered corticosteroids hold the same if not superior results for patients with acute exacerbation of COPD. This research should be sufficient to reduce the health care costs imposed by COPD because it is one of the leading problems in the United States. Low doses of corticosteroids orally would result in lower adverse effects along with reduced cost and hospital stay. Hence the results of this research should be effectively utilized. GENERALIZABILITY/CRITIQUE/DISCUSSION Positive Attributes: Used appropriate statistical tests An important research which can provide many beneficial results with regard to health costs as well as benefit the patients. Proper inclusion criteria of patients based not only on the record of the hospital but also on the data maintained by the Premier Incorporated’s Perspective. The confidence interval was 95%. Negative Attributes: The data was based mainly on the records which were maintained in the Premier Incorporated’s Perspective. 414 hospitals which only lay under the Premier Incorporated’s Perspective were used and no other hospitals were included in the research. The analysis was done only the United States and not conducted in the hospitals of other countries to attain better results. About 92 percent of the patients were given intravenous therapy whereas just 8 percent were given oral corticosteroids. Thus for better analysis of the effectiveness of oral corticosteroids, more patients on oral corticosteroids should have been assessed. Clinical Application: Not useful for patients who are unconscious or cannot take the drug orally due to other problems. It is also not useful for patients who are directly put on mechanical ventilation. Oral administration is also not totally free of adverse effects with oral candidiasis being one such adverse effect. References: 1. Top of Form Finkel, Richard, Michelle A. Clark, Luigi X. Cubeddu, Michael Cooper, Christopher T. Flatt, and Laura OLeary.Pharmacology: Lippincotts Illustrated Reviews. Philadelphia [etc.: Lippincott Williams & Wilkins, 2009. Print. 2. Top of Form Top of Form Kumar, Vinay, Abul K. Abbas, Nelson Fausto, Stanley L. Robbins, and Ramzi S. Cotran. Robbins and Cotran Pathologic Basis of Disease. Philadelphia: Elsevier Saunders, 2005. Print. 3. Top of Form Katzung, Bertram G. Basic & Clinical Pharmacology. New York: Lange Medical Books/McGraw Hill, 2004. Print. Bottom of Form Bottom of Form Bottom of Form 4. Top of Form Lindenauer, Peter K, Penelope S. Pekow, Maureen C. Lahti, Yoojin Lee, Evan M. Benjamin, and Michael B. Rothberg. "Association of Corticosteroid Dose and Route of Administration with Risk of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease." Jama : the Journal of the American Medical Association. 303.23 (2010): 2359. Print. Bottom of Form 5. Top of Form Top of Form ODonnell, DE, S Aaron, J Bourbeau, P Hernandez, D Marciniuk, M Balter, G Ford, A Gervais, R Goldstein, R Hodder, F Maltais, and J Road. "Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease-2003." Canadian Respiratory Journal : Journal of the Canadian Thoracic Society. 10 (2003). Print. Bottom of Form Bottom of Form Bottom of Form Read More