Antibiotics and Systemic Corticosteroids Effective for Treating COPD Exacerbation

By Will Boggs, MD, Reuters Health
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Antibiotics and systemic corticosteroids are effective for treating patients with mild to severe exacerbations of chronic obstructive pulmonary disease (COPD), according to a systematic review and meta-analysis.

"Based on our findings, I would reassure physician colleagues that they should use antibiotics and systemic corticosteroids in any exacerbation of COPD," Dr. Claudia C. Dobler from Mayo Clinic, Rochester, Minnesota, and Gold Coast University Hospital, Gold Coast, Queensland, Australia told Reuters Health by email. "It is likely that in the future we will able to determine better which patients stand to benefit the most from these interventions and which patients might not benefit (based on biomarkers including CRP or procalcitonin for antibiotics and blood eosinophils for systemic corticosteroids), but I do not think that we are quite there yet."

Antibiotics, systemic corticosteroids, and short-acting bronchodilators are the mainstays of treating COPD exacerbations. Whether patients across the spectrum of exacerbation severity benefit from these and other pharmacologic treatments remains uncertain.

Dr. Dobler and colleagues evaluated the comparative effectiveness and adverse events of pharmacologic interventions for adults with exacerbation of COPD in their systematic review of 68 randomized controlled trials that included 10,758 participants.

In the short term (at the end of the intervention), compared with placebo or management without intervention, antibiotics were associated with 2.03-fold greater odds of exacerbation resolution and 46% lower odds of treatment failure, and systemic corticosteroids were associated with 99% lower odds of treatment failure, independent of exacerbation severity and study setting, according to the online report in Annals of Internal Medicine.

Neither treatment was associated with significant differences in death, hospital admission, repeated exacerbations, or the need for intubation.

In contrast, there was insufficient evidence to demonstrate effectiveness of aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, or short-acting bronchodilators.

There was also insufficient evidence or no evidence informing the optimal choice of specific antibiotic or corticosteroid treatment regimen.

"While antibiotic stewardship considerations are generally important, physicians should not feel guilty if they prescribe antibiotics in patients who only have a mild exacerbation of COPD," Dr. Dobler said. "The evidence is on their side. The same applies to systemic corticosteroids."

"I would discourage anybody from using unproven treatments, such as aminophyllines and magnesium sulfate," she said.

"There is increasing evidence that some non-pharmacologic therapies, especially exercise started early during an episode of exacerbation, may lead to functional improvements in hospitalized patients with moderate to severe exacerbation of COPD," Dr. Dobler added. "The American Thoracic Society/European Respiratory Society guidelines published in 2017 included a conditional recommendation (very low quality of evidence) to not initiate pulmonary rehabilitation during hospitalization for exacerbation of COPD, but I think it is likely that we will see a change in this recommendation in coming years."

SOURCE: Annals of Internal Medicine, online February 24, 2020.


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