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• W2046296614 abstract "Patients who “fail to do well,” (relapse promptly after treatment) may be considered guilty of contributing to their own ill health through non-compliance. At least one study has tried to prevent such recidivism in patients with reversible airflow obstruction by injecting a long-acting intramuscular corticosteroid at the time of the initial visit.1Hoffman IB Fiel SB Oral vs repository corticosteroid therapy in acute asthma.Chest. 1988; 93: 11-13Crossref PubMed Scopus (37) Google Scholar In patients with COPD, the causes for relapse may be multiple, and include exacerbation of airflow obstruction which theoretically could respond to steroid administration. Proof of a causal role for reversible airflow obstruction in relapses of COPD or of a beneficial effect of steroids has been difficult to obtain. Although hospitalized patients treated with steroids showed a greater responsiveness to bronchodilator therapy after 12 hours, no impact of steroid on length of hospital stay was reported2Albert RK Martin TR Lewis SW Controlled clinical trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency.Ann Intern Med. 1980; 92: 753-758Crossref PubMed Scopus (240) Google Scholar and steroid administration to patients in an emergency department (ED) setting did not reduce admission rates.3Emerman CL Connors AF Lukens TW May ME Effron D A randomized controlled trial of methylprednisolone in emergency treatment of acute exacerbations of COPD.Chest. 1989; 95: 563-567Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar The study by Murata et al in this issue (see page 845) suggests that steroid administration has a beneficial effect on relapse rate in patients with COPD who are prone to relapse (my emphasis). Although their study is retrospective, the criteria used to match visits in the same patient include the major therapeutic confounders, and the post-matching analysis of other variables which might be considered to influence outcome reveals no major difference. The reduction in relapse rates they report is of clinically important magnitude, and if confirmed in a prospective study would provide strong evidence for the use of steroids in patients with COPD who are prone to relapse. I have emphasized the relapsing aspect for four reasons. First, this is a population of interest clinically, in that it represents 20 percent of patients with respiratory distress seen in the ED.4Murata GH Gorby MS Chick TW Halperin AK Use of emergency medical services by patients with decompensated obstructive lung disease.Ann Emerg Med. 1989; 18: 501-506Abstract Full Text PDF PubMed Scopus (39) Google Scholar Second, because the negative results of previous trials may have occurred because the “relapse prone” subgroup was eclipsed by the greater number of non “relapse prone” patients. Third, because the “relapse prone” population can be identified by history without recourse to further investigations (sputum or blood eosinophilia) which have been variably successful in identifying stable COPD patients who improve on steroids.5Shim C Stover DE Williams MH Response to corticosteroids in chronic bronchitis.J Allergy Clin Immunol. 1978; 62: 363-367Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 6Harding SM Freedman S A comparison of oral and inhaled steroids in patients with chronic airway obstruction.Thorax. 1978; 33: 214-218Crossref PubMed Scopus (53) Google Scholar Fourth, because although Murata et al state that there was no difference between their “relapse prone” and non “relapse prone” patients with respect to bronchodilator response and that they excluded patients with asthma, a 20 percent improvement in FEV1 was seen in both groups of patients. This suggests that assessment of such reversibility of airflow obstruction may be unimportant in deciding whether to give steroids or not, and that the key factor should be the “relapse prone” history. From the beneficial effects of steroids on relapse rate in “relapse prone” COPD patients, and considering the possible beneficial properties of steroids in such decompensated COPD patients as discussed by Murata et al, it is likely that modulation of the inflammatory response process plays a key role. Viewed in this light, the therapeutic issues in management of the “relapse prone” COPD patient appear very similar to those relating to the treatment of acute bronchial asthma, with increasing agreement that steroids should be used early rather than late.7Fiel SB Swartz MA Glanz K Francis ME Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma.Am J Med. 1983; 75: 259-262Abstract Full Text PDF PubMed Scopus (105) Google Scholar The optimal steroid regimen is still unclear. Murata et al used a combination of intravenous and oral steroids. It is probably important, as they suggest, that steroids be continued for some days to allow reversal of the inflammatory response. The need for parenteral steroid administration in addition to oral is not proven, and should be studied in view of the very infrequent, but potentially severe acute myopathy reported with parenteral steroid administration.8Williams TJ O'Hehir RE Czarny D Home M Bowes G Acute myopathy in severe acute asthma treated with intravenously administered corticosteroids.Am Rev Respir Dis. 1988; 137: 460-463Crossref PubMed Scopus (116) Google Scholar The potential role of inhaled steroid using the higher dose metered aerosols should also be explored. If the findings in the study of Murata et al are substantiated, then the recidivist when a “relapse prone” patient relapses is likely to be not the patient, but the physician who did not prescribe steroids." @default.
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