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Journal Club

Journal Club. August 2, 2013. Objectives. Discuss whether a shorter course of glucocorticoids is overall better for Acute Exacerbations of Chronic Obstructive Pulmonary Disease . Define what patients are at higher risk for Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

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Journal Club

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  1. Journal Club August 2, 2013

  2. Objectives • Discuss whether a shorter course of glucocorticoids is overall better for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. • Define what patients are at higher risk for Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

  3. Background • Exacerbations of respiratory symptoms in chronic obstructive pulmonary disease have significant and long-lasting effects on patients including prolonged hospitalization and side effects from treatment.

  4. JAMA, June 5, 2013—Vol 309, No. 21

  5. Overview • Objective: whether short-term (5 days) is inferior to conventional (14 days) treatment with steroids for COPD and whether it decreases exposure to steroids • Design: randomized, noninferiority multicenter trial in Swiss teaching hospitals from 3/2006-2/2011 • Interventions: 40mg prednisone daily for either 5 or 14 days in placebo-controlled, double-blind fashion. Predefined noninferiority criterion was absolute increase in exacerbations of at most 15% or critical HR of 1.515 for reference event rate of 50% • Outcome: time to next exacerbation within 180 days

  6. Limitations • All patients given antibiotics • All patients given inhaled steroids, LABA, and tiotropium • All patients were current or former smokers

  7. So… what are the experts doing? • Dr. Antonio Anzueto on the GOLD committee • Going to review the REDUCE trial at next meeting • We are finding that less steroids is better • He uses prednisone 20mg x 5 days • Recommends Hospital Medicine remind patients that 30% of patients with AECOPD are not back to their baseline in one month and that we limit the use of short acting bronchodilators in the inpatient setting

  8. JAMA, June 12, 2013—Vol 309, No. 22

  9. Overview • Design: prospective cohort study examining 6574 COPD patients from Copenhagen Population and Heart Study (2001-2008) • Main Outcomes and Measures: baseline CRP, fibrinogen, leukocyte count measured during asymptomatic period and during exacerbations

  10. GOLD Executive Summary 2013

  11. Gold Executive Summary 2013

  12. Discussion • Risk of exacerbation increased 4-fold in 1st year with 3 high inflammatory markers • Subgroup of patients with COPD have increased biomarkers during stable conditions and they seem to be prone to future exacerbations

  13. References • Inflammatory Biomarkers and Exacerbations in Chronic Obstructive Pulmonary Disease. Mette Thomsen, MD; Truls Sylvan Ingebrigtsen, MD; Jacob Louis Marott, MSc; et al. JAMA. 2013;309(22):2353-2361. doi:10.1001/jama.2013.5732. • Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: The REDUCE Randomized Clinical Trial. Jörg D. Leuppi, MD, PhD; Philipp Schuetz, MD; Roland Bingisser, MD; et al. JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023. • GOLD Executive Summary 2013

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