title: Outcomes associated with corticosteroid dosage in critically ill patients with acute exacerbations of chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Studies evaluating corticosteroid (CS) dosing for patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) have largely excluded patients admitted directly to the intensive care unit (ICU), and none have evaluated the effect of CS dosing regimens on mortality.
  
  
  OBJECTIVE
  To examine the effectiveness and safety of lower- versus high-dose CS in patients admitted to the ICU with an AECOPD.
  
  
  METHODS
  This pharmacoepidemiologic cohort study evaluated ICU patients with AECOPD admitted to one of 473 hospitals and treated with CS within the first 2 days between January 1, 2003 and December 31, 2008. Patients were grouped into lower-dose (methylprednisolone, ≤240 mg/d) or high-dose (methylprednisolone, >240 mg/d) groups based on CS dosage on hospital Day 1 or 2. The primary outcome was hospital mortality.
  
  
  RESULTS
  A total of 17,239 patients were included; 6,156 (36%) were in the lower-dose and 11,083 (64%) in the high-dose CS group. After propensity score matching and adjustment for unbalanced covariates, lower-dose CS was not associated with a significant reduction in mortality (odds ratio, 0.85; 95% confidence interval [CI], 0.71-1.01; P = 0.06), but it was associated with reduced hospital (-0.44 d; 95% CI, -0.67 to -0.21; P < 0.01) and ICU (-0.31 d; 95% CI, -0.46 to -0.16; P < 0.01) length-of-stay, hospital costs (-$2,559; 95% CI, -$4,508 to -$609; P = 0.01), length of invasive ventilation (-0.29 d; 95% CI, -0.52 to -0.06; P = 0.01), need for insulin therapy (22.7% vs. 25.1%; P < 0.01), and fungal infections (3.3% vs. 4.4%; P < 0.01).
  
  
  CONCLUSIONS
  Two-thirds of patients admitted to the ICU with an AECOPD are treated with high doses of CS that are associated with worse outcomes and more frequent adverse effects. Lower dosage strategies should be encouraged for patients admitted to the ICU and the optimum dose should be determined through clinical trials.
authors.affiliation: 1 Department of Clinical Pharmacy.
authors.forename: Tyree H
authors.initials: TH
authors.lastname: Kiser
authors.forename: Richard R
authors.initials: RR
authors.lastname: Allen
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Valuck
authors.forename: Marc
authors.initials: M
authors.lastname: Moss
authors.forename: R William
authors.initials: RW
authors.lastname: Vandivier
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000627:therapeutic use; D015331:Cohort Studies; D016638:Critical Illness; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage / Q000627:therapeutic use*; D008875:Middle Aged; D015999:Multivariate Analysis; D017891:Pharmacoepidemiology; D057216:Propensity Score; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy* / Q000401:mortality
chemical_list: D000305:Adrenal Cortex Hormones; D000893:Anti-Inflammatory Agents; D008775:Methylprednisolone