1. Steroid Use in Acute Exacerbations of COPD Katherine Kielts, Pharm.D. PGY2 Critical Care Resident St. Vincent Indianapolis Hospital September 17, 2015 This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

2. Pathophysiology of COPD 2 http://www.nhlbi.nih.gov/health//dci /Diseases/Copd/Copd_WhatIs.html

3. Rationale for Steroid Use Reduce capillary permeability Inhibit neutrophil degranulation Inhibit prostaglandins 3 Rationale for Steroid Use Rodriquez-Rosin. Thorax. 2006 Prednisone. Micromedex. 2015 http://conditions.healthguru.com/video/c opd-complications

4. 4 Steroids: Benefits and Risks Walters. Cochrane Libr. 2009 Bahloul. Am J Ther. 2013 Rodriquez-Rosin. Thorax. 2006 Alia. Arch Intern Med. 2011 Vrie. BMC Fam Pract. 2013 BenefitsRisks Improvement in FEV 1 Hypertension Reduce rate of 30 day hospital readmission Need for mechanical ventilation Length of ICU and hospital stay Severity of dyspnea Re-exacerbation Hyperglycemia Increased risk of infection Fluid retention Adrenal suppression

5. The REDUCE Trial GOLD Guideline recommendation: prednisone 40mg daily for 5 days Objective: Prednisone 40mg daily x 5 days versus prednisone 40mg daily x 14 days (n = 314) Primary outcome: Time to next exacerbation Results No difference in re-exacerbation rates or steroid-related adverse effects Less cumulative steroid exposure in short-term group Conclusions Five days is noninferior to 14 days 5 Leuppi. JAMA. 2013 GOLD Guidelines. 2015

6. REDUCE Limitations Exclusion Criteria History of asthma Radiological diagnosis of pneumonia Estimated survival of less than 6 months due to severe comorbidity Standardized treatment Lack of standardization of steroid dosing 6 Leuppi. JAMA. 2013

7. Steroid Use in Mechanically Ventilated Patients Very limited data on treatment of acute COPD exacerbations in patients requiring mechanical ventilation Most studies conducted outside the ICU Exclusion of mechanically ventilated patients Mechanical ventilation = treatment failure 7 Abroug. Eur Respir J. 2014 Alia. Arch Intern Med. 2011 GOLD Guidelines. 2014 Kiser Am J Respir Crit Care Med. 2014

8. Readmission Reduction and Hospital Discharge Steroid and/or antibiotic instruction Assess and educate home maintenance pharmacotherapy Inhaler technique Exacerbation prevention education Plan follow-up visit Assess need for oxygen therapy 8 GOLD Guidelines. 2015

9. Learning Assessment Question What is the steroid dose and duration recommended by the GOLD Guidelines per the REDUCE trial? A.Prednisone 40mg by mouth daily x 14 days B.Methylprednisolone 40mg IV daily x 5 days C.Prednisone 40mg by mouth daily x 5 days D.Methylprednisolone 40mg IV daily x 14 days 9

10. Steroid Use in Acute Exacerbations of COPD Katherine Kielts, Pharm.D. PGY2 Critical Care Resident St. Vincent Indianapolis Hospital September 17, 2015