Corticosteroid dosing in the treatment of acute exacerbations of COPDKurt A. Wargo, Pharm.D., BCPS, Takova D. Wallace, Pharm.D. Candidate 2014, Ryan E. Owens, Pharm.D. Candidate 2014

Auburn University Harrison School of Pharmacy & Huntsville Hospital

Objective Results Results ResultsThe goal of this study was to compare current practice trends in an 881-bed community hospital in North Alabama to established GOLD guideline recommendations for corticosteroid dosing in patients presenting during a COPD exacerbation. The GOLD guidelines offer specific recommendations for corticosteroid dosing, suggesting the administration of prednisolone 30 – 40 mg daily by mouth for 10 – 14 days. Clinically in our institution, we have recognized a trend in prescribers not following these guidelines, with much larger doses of intravenous (IV) corticosteroids being administered. Therefore, the main outcomes assessed in this study were: 1) evaluation of corticosteroid prescribing practices 2) impact of glycemic control while on steroids

Methods

Conclusions

• Institutional Review Board approved•Retrospective, chart analysis conducted at an 881-bed regional referral hospital

Exclusion criteria:• Intensive care treatment•< 40 years of age•Concurrent respiratory disease

Procedure:•Medical history, specific pharmacotherapy for COPD prior to admission, in-hospital pharmacotherapy, and therapy upon hospital discharge were collected for analysis utilizing electronic medical records•Diabetes status and elevations of glucose levels >180 mg/dL were recorded

Table 1. Baseline Demographics

The authors have no financial or personal relationships with any commercial entities to disclose

Figure 3. Glucose trends in corticosteroid-induced hyperglycemia

  MaleN=99

FemaleN=101

Age, yrs ± SD 68.2 ± 11.22 70.1 ± 9.96 

African-American (n) 16 

10

Caucasian (n) 

82 

91 

Hispanic (n) 1 

0

Home COPD Meds (n) None SABA SABA + SAAC Tiotropium Other combinations Theophylline Roflumilast Home O2

 157345227542

36

 197341218210

24

Concurrent Diseases (n) CHF MI Diabetes

 142333

 9

1521 Day 1

Day 2Day 3

Day 4Day 5

Day 6Day 7

Day 8Day 9 Da

0

50

100

150

200

250

No InsulinInsulin Initiated

DiscussionTable 2. Corticosteroid Dosing

This study demonstrates the need for education on corticosteroid dosing in COPD exacerbations and the need to closely monitor glucose levels, especially in patients with diabetes

  MaleN = 95

FemaleN = 95

Initial dose (n) Methylprednisolone 125 mg IV Methylprednisolone 80 mg IV Methylprednisolone 60 mg IV Methylprednisolone 40 mg IV Other dose or drug

 509

20106

 511220102

Cumulative dose (mg) 1253 (80 – 8310)

• Corticosteroid dosing for acute exacerbations was found to be substantially higher & inconsistent with the GOLD guidelines

• In spite of the larger doses, the hospital length of stay was not impacted

• A large number of patients experiencing hyperglycemia• Cumulative steroid dosing was lower among patients with

diabetes; however, those patients were more likely to develop hyperglycemia

0 mg (n = 15)

< 500 mg (n = 49)

500-1000 mg (n = 62)

1001-1500 mg (n=37)

> 1500 mg (n = 37)

Cumulative Steroid Dose

0

1

2

3

4

5

6

7

8

5.5 4.6 5.1 5.6 7.1

Da

ys

Figure 2. Hospital Length of Stay Based Upon Corticosteroid Dose

< 500 mg (n = 49)

500 - 1000 mg (n=62)

1000 - 1500 mg (n = 37)

> 1500 mg (n = 37)

Average Steroid Dose

0

500

1000

1500

2000

2500

3000

3500

4000

332 723 1161 3455

Figure 1. Average Corticosteroid Dose

Diabetes(n=54)

No Diabetes(n=146)

Glucose > 180 on steroids (n, %)

49 (91) 42 (29)

Cumulative steroid dose (mg), (Avg ± SD, range)

928 ± 1107(80 – 5110)

1687 ± 1756(175-7665)

Table 3. Glucose levels and steroid dosing in patients with and without diabetes