{'fraction_non_alphanumeric': 0.04053514376996805, 'fraction_numerical': 0.02615814696485623, 'mean_word_length': 5.034939759036145, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 5, 'https://': 0, 'lorem ipsum': 0, 'www.': 2, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Review: 7 and >7 days of systemic corticosteroids do not differ for efficacy in COPD exacerbations

Question In patients with acute exacerbations of chronic obstructive pulmonary disease (COPD), is short-duration therapy with systemic corticosteroids (SCSs) as effective as longer-duration therapy? Review scope Included studies compared SCS therapy for 7 days with therapy for >7 days in adults with acute COPD exacerbations. Studies of patients with asthma or other lung diseases were excluded unless data for patients with COPD only were provided separately. Outcomes included treatment failure (need for additional treatment, return to emergency department or hospital, or unscheduled physician visit), relapse, death, and adverse drug effects. Review methods Cochrane Airways Group Register of Trials (Jun 2014), which includes studies identified from Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE/Excerpta Medica, CINAHL, AMED, PsycINFO, and hand-searches of respiratory journals and meeting abstracts; MEDLINE, EMBASE/Excerpta Medica, CINAHL, and Cochrane Central Register of Controlled Trials (Mar 2014); and reference lists, www.clinicaltrials.gov, and www.who.int/ictrp/en/ were searched for randomized controlled trials (RCTs). 8 RCTs (n =582, mean age 65 to 73 y, 58% to 94% men) met the selection criteria; all were set in hospitals. Short-duration therapies were 3, 5, or 7 days; longer-duration therapies were 10, 14, or 15 days. 4 RCTs had adequately generated randomization sequences, 4 had adequate allocation concealment, and 4 were double-blind. Main results Short- and longer-duration treatment with SCSs did not differ for treatment failure, relapse, death, hyperglycemia, or hypertension (Table). Conclusion In patients with acute exacerbations of chronic obstructive pulmonary disease, short- and longer-duration therapies with systemic corticosteroids did not differ for treatment failure or death. Short- (7 d) vs longer- (>7 d) duration therapy with systemic corticosteroids in acute exacerbations of chronic obstructive pulmonary disease* Outcomes Number of trials (n) Weighted event rates RRR (95% CI) NNT Short Longer Treatment failure 4 (457) 6.3% 8.3% 26% (42 to 62) Not significant Death 2 (336) 6.7% 7.7% 8% (95 to 57) Not significant Hyperglycemia 2 (345) 44% 44% 1% (25 to 21) Not significant Hypertension 1 (311) 9.6% 15% 35% (19 to 65) Not significant RRI (CI) NNH Relapse 4 (478) 31% 30% 3% (21 to 34) Not significant *Abbreviations defined in Glossary. Weighted event rates, RRR, RRI, and CI calculated from data in article using a fixed effect model. Commentary The SCS efficacy review by Walters and colleagues supports the use of SCSs for the treatment of COPD exacerbations, but the benefits are small and not without risk. Improvement in lung function with SCSs was not apparent beyond 72 hours, and length of hospital stay was reduced by just >1 day compared with placebo. No reductions were found for duration of ventilator support or short-term mortality, although the latter may reflect the low death rate observed in the primary studies, possibly due to recruitment bias. Such a bias may not be important in this context because the riskbenefit ratio would still justify treatment in patients with the most severe disease. Set against the reduction in treatment failure (number needed to treat of 9), there were significant risks, particularly for hyperglycemia (number needed to harm of 6 for adverse drug effects), so patients were more likely to have a side effect than avoid a treatment failure. There was no evidence for a benefit of parenteral over oral SCSs, and because the latter is a safer means of administration, the review favors the oral route. Most trials in the review included hospitalized patients, but data from the smaller number of outpatient trials suggest that a similar treatment response in this setting. No information was provided about patient subgroups, but it is reasonable to use oral SCSs only in patients who have worsening breathlessness that is clearly affecting their daily activities. The studies in the SCS efficacy review by Walters and colleagues generally used a medium-high dose of SCSs (30 mg prednisolone equivalent) for 7 days. Walters and colleagues' second review addressed the question of whether treatment duration matters. The review included 8 RCTs that compared treatment for <7 days with treatment for 7 days and included only patients with severe exacerbations. Most trials were small, so the meta-analyses were dominated by the results of the emergency departmentbased REDUCE trial (1), which contributed >50% of the patients in the efficacy and adverse event analyses. REDUCE found that 5 days of prednisone, 40 mg/d, was noninferior to the same dose for 14 days (1). The trial was of good size (n =314) and quality, and there was little evidence of heterogeneity between it and the smaller studies. Thus, this result is probably reliable. A 5-day course of SCSs seems to be adequate.