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Corticosteroids for Pneumonia

Corticosteroids for Pneumonia. Prof Dr Sait Karakurt Marmara University Medical S chool Pulmonary and Critical Care Medicine. Conflict of interest. Novartis Astra Zeneca Glaxo Smith Kline Chiesi Boehringer Ingelheim Sanovel MSD Abdi İbrahim Actelion. Outlines.

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Corticosteroids for Pneumonia

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  1. CorticosteroidsforPneumonia Prof Dr Sait Karakurt Marmara UniversityMedicalSchool PulmonaryandCriticalCareMedicine

  2. Conflict of interest • Novartis • AstraZeneca • GlaxoSmithKline • Chiesi • BoehringerIngelheim • Sanovel • MSD • Abdi İbrahim • Actelion

  3. Outlines • Effects of corticosteroids • Adrenal response in pneumonia • Corticosteroidsforpneumonia • 1. Is the occurrence of relative adrenal insufficiency a possiblerationale for using corticosteroids in pneumonia? • 2. Do corticosteroids shorten symptoms in mild pneumonia? • 3. Do corticosteroids reduce mortality and the incidence ofpneumonia complications such as severe sepsis or ARDS in severe pneumonia? • 4. Are there any dose-effect relationships betweencorticosteroidsandpneumonia? • Conclusions

  4. "Except on few occasions, the patient appears to die from the body's response to infection rather than from it" SirWilliam Osler, 1904

  5. Corticosteroids • Corticosteroids influence • immune regulation • carbohydratemetabolism • protein catabolism • electrolytebalance • stress response

  6. Corticosteroidsandinflammation • Corticosteroidspreventactivation of proinflammatorygenesbypreventingactivation of NF-kB • Corticosteroidshaveantiinflammatoryeffectsbyactivation of histondeacetylase

  7. Corticosteroids • Corticosteroids act partly by inducinganti-inflammatory genes which repress inflammatory genes • They are used for treating inflammatory diseasesof the bowel (colitis), joints (arthritis), skin (dermatitis) andlungs (asthma)

  8. Systemic corticosteroids • Systemic corticosteroids 1-critical illness-related corticosteroidinsufficiency (CIRCI) 2-refractory septicshock 3-reduced pulmonary inflammation in patients with bacterialpneumonia and acute lung injury 4-improved oxygenationand outcomes in patients with Pneumocystis jiroveciipneumonia.

  9. Outlines • Effects of corticosteroids • Adrenal response in pneumonia • Corticosteroidsforpneumonia • 1. Is the occurrence of relative adrenal insufficiency a possiblerationale for using corticosteroids in pneumonia? • 2. Do corticosteroids shorten symptoms in mild pneumonia? • 3. Do corticosteroids reduce mortality and the incidence ofpneumonia complications such as severe sepsis or ARDS in severe pneumonia? • 4. Are there any dose-effect relationships betweencorticosteroidsandpneumonia? • Conclusions

  10. Adrenal Response in Severe CAP-relative adrenal insufficiency • Critical Illness-RelatedCorticosteroidInsufficiency(CIRCI)was diagnosed in 40.8% of thepatients. • Critical illness-related corticosteroid insufficiency (CIRCI) was defined as a total baselinecortisol<15 microg/dLor a postcorticotropinelevation<9 microg/dL. JF Salluh et al. CHEST 2008; 134:947–954

  11. Adrenal Response in Severe CAP-relative adrenal insufficiency JF Salluh et al. CHEST 2008; 134:947–954

  12. Adrenal Response in Severe CAP-mortalityaccordingtocortisollevels JF Salluh et al. CHEST 2008; 134:947–954

  13. Adrenal Response in Severe CAP-survival JF Salluh et al. CHEST 2008; 134:947–954

  14. Adrenal Response in Severe CAP-Baseline Cortisol Levels, CURB-65, andAPACHE II Score Thresholds To Predict Mortality JF Salluh et al. CHEST 2008; 134:947–954

  15. Outlines • Effects of corticosteroids • Adrenal response in pneumonia • Corticosteroidsforpneumonia • 1. Is the occurrence of relative adrenal insufficiency a possiblerationale for using corticosteroids in pneumonia? • 2. Do corticosteroids shorten symptoms in mild pneumonia? • 3. Do corticosteroids reduce mortality and the incidence ofpneumonia complications such as severe sepsis or ARDS in severe pneumonia? • 4. Are there any dose-effect relationships betweencorticosteroidsandpneumonia? • Conclusions

  16. HydrocortisoneInfusionforSevere Community-acquiredPneumonia-clinicalandphysiologicalcharacteristics M Confalonieri et al. Am J RespirCrit Care Med Vol 171. pp 242–248, 2005

  17. HydrocortisoneInfusionfor Severe Community-acquiredPneumonia-CRPand PaO2:FIO2 M Confalonieri et al. Am J RespirCrit Care Med Vol 171. pp 242–248, 2005

  18. HydrocortisoneInfusionfor Severe Community-acquiredPneumonia-survival curves and time to removal of MV M Confalonieri et al. Am J RespirCrit Care Med Vol 171. pp 242–248, 2005

  19. HydrocortisoneInfusionforSevere Community-acquiredPneumonia-outcome M Confalonieri et al. Am J RespirCrit Care Med Vol 171. pp 242–248, 2005

  20. Hydrocortisone Infusion for Severe Community-acquired Pneumonia-major complications M Confalonieri et al. Am J RespirCrit Care Med Vol 171. pp 242–248, 2005

  21. The role of corticosteroids in severe community-acquiredpneumonia: a systematicreview Jorge IF et al CriticalCare 2008

  22. The role of corticosteroids in severe community-acquiredpneumonia: a systematicreview Jorge IF et al CriticalCare 2008

  23. The role of corticosteroids in severe community-acquiredpneumonia: a systematicreview • Allfour studies failed to show worse outcomesassociated with the use of corticosteroids. • Thus, it may be reasonableto conclude that, in patients with COPD or asthmareceivingantimicrobialtherapy, corticosteroidadministrationmaybe consideredsafe. Jorge IF et al CriticalCare 2008

  24. Corticosteroidsand CAP-etiologic pathogen • The etiologic pathogen of CAP may also play a role in thepotential benefit of corticosteroids • Corticosteroidsreduce mortality in acquired immunodeficiencysyndrome(AIDS) patientswithPneumocystisjiroveciipneumoniaandsignificanthypoxemia

  25. Corticosteroidsand CAP-etiologic pathogen • Patientswith documented S. pneumoniae had worse outcome whentreated with corticosteroids • Atrend toward aworse outcome with pneumococcal CAPspecifically excludedmacrolide treatment to demonstrate the independentimmunomodulatorybenefits of corticosteroids. • Corticosteroidtherapy of acute lung injury associated with thenovel 2009 H1N1 influenza A was associated with increasedcomplications, mainly nosocomial pneumonia, and a trendtowardincreasedmortality.

  26. EarlyCorticosteroids in Severe Influenza A/H1N1 Pneumonia and ARDS ChristianBrun-Buisson et al, Am J RespirCrit Care Med, 2011

  27. Corticosteroidsforpneumonia Conclusions-1 • Inmildpneumonia, corticosteroids can improve clinical symptoms andreduce the rate of relapse. • In severe pneumonia, corticosteroids can improve oxygenation and clinical symptoms, reduce mechanical ventilation and length of stay in ICU. Corticosteroidsforpneumonia, TheCochraneLibrary, 2011

  28. CorticosteroidsforpneumoniaConclusions-2 • There is insufficient evidence toconfirm whether they can reduce mortality and resolve pneumonia. • Do not recommend the use of steroids for respiratory syncytialvirus-infected children with pneumonia because there is nosignificant benefit for the patient. • Recommendcorticosteroids forM. pneumoniaeinfected children because corticosteroidscan significantly relieve clinical symptoms and preventrelapseof thedisease. Corticosteroidsforpneumonia, TheCochraneLibrary, 2011

  29. CorticosteroidsforpneumoniaConclusions-3 • Studiesdid not compare theeffects of different doses of corticosteroids and so we are unable tomake any recommendations with regards to the dosage of corticosteroids in clinicalpractice. Corticosteroidsforpneumonia, TheCochraneLibrary, 2011

  30. "Except on few occasions, the patient appears to die from the body's response to infection rather than from it" SirWilliam Osler, 1904

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