Level 2: Mid-level evidence

High-dose IV corticosteroids are widely prescribed for patients admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD), despite guidelines recommending oral steroids at lower doses. An analysis of 79,985 patients who received steroids for COPD exacerbation at 414 centers found that 92% were initially treated with IV steroids, while only 8% initially received oral steroids (JAMA. 2010;303:2359-2367). However, outcome measures suggest that oral steroids for initial treatment may be at least as effective as IV steroids. Over the first two days, median doses (prednisone equivalents) were 60 mg in patients receiving oral steroids and 600 mg in patients receiving IV steroids. A total of 1,356 patients (22%) initially prescribed oral steroids were switched to IV steroids during hospitalization.

The primary measure was treatment failure, defined as the composite of three outcomes: in-hospital mortality, initiation of mechanical ventilation after the second hospital day, and readmission for acute exacerbation of COPD within 30 days. Treatment failure occurred in 10.3% of the oral group and 10.9% of the IV group. In-hospital mortality was significantly lower in the oral group (1% vs. 1.4%, P=0.01).

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To control for potential baseline differences, a subgroup analysis compared patients from the two groups that were matched by “propensity scores” for initial treatment with oral steroids. Propensity scores were based on patient characteristics (including demographic and insurance factors), comorbidities, all other early treatments and diagnostic tests, and hospital characteristics. Initial treatment with oral steroids was associated with reduction in risk of treatment failure (odds ratio 0.84, 95% CI 0.75-0.95), shorter hospital stay (odds ratio 0.9, 95% CI 0 0.88-0.91) and lower hospital costs (odds ratio 0.91, 95% CI 0.89-0.93).