Corticosteroids In COPD Summary
The use of inhaled corticosteroids in COPD
In this study published in JAMA, the authors looked at eleven studies on the use of inhaled corticosteroids in patients with COPD defined as a smoking- related lung disease characterized by recurrent episodes of cough, sputum production and breathlessness (Drummond, 2407). The authors of this study did no research of their own, but instead looked at other double blind, randomized, placebo controlled studies from around the world, with a restriction that the study was published, lasted longer than six months and looked at ICS use compared to a control group (2408). These were searched for using medical databases and the reference sections of studies they considered. Two reviewers independently screened …show more content…
studies for inclusion and determined study eligibility with disagreements resolved by group consensus (2408) This is where the first issue arises. The authors themselves did not do any of the testing, but only looked at other’s results. Even though these studies were randomized studies, there could still be author bias in which studies were chosen, and this could skew the results. The next issue is that while 11 studies were chosen, not every study was compared to every other study, but usually only to a few studies. Therefore the results only reflect which studies were compared to each other, not the whole group. Data used in the met-analysis included study methodology, design, intervention, and main results (2408)
The primary outcome focused on was all cause mortality one year after initiation of use of inhaled corticosteroids.
As the studies all used different inhaled steroids at different doses, all were converted to the equivalent dose of beclomethasone, with conversion disagreements again settled by consensus (2408) . This means that there again was study bias as the conversion is not an exact similar dose. Not all the studies used matched all the criteria, including placebo control, combo therapy with a long acting beta agonist (LABA) and steroid alone trials. (2409) I myself found this to be very confusing as you never know which study provided which results, and how these results were interpreted. However, no study found a statistically significant 1-year mortality benefit from ICS use as compared with placebo …show more content…
(2409-2410)
Multiple secondary outcomes were also evaluated including risk of pneumonia and fractures in people taking the ICS. The first of these secondary outcomes involved the risk of pneumonia reported in seven of the studies (2411). Those seven studies looked at 10,776 patients comprised of 5405 patients in the treatment group and 5371 patients in the control group (2411). These groups represent relatively equal size study groups of a decent size. It should be noted that 61.9% of the data came from three studies. (2411). Despite this, there seemed to be a higher incidence of pneumonia among those taking ICS therapy, per the study RR 1.34;95% CI, 1.03-1.75; P=.03 (2411), or a 34% increased risk of pneumonia (2412). Furthermore, only two of the studies had clearly defined (and different) definitions of pneumonia (2412). It should also be noted that some of the pneumonia events could have been misclassified as pneumonia when they really were COPD exacerbations. (2414)
Fracture incidence was the third parameter looked at.
Three of the studies reported fracture events. (2412). In the control group, there were 178 events among 4058 subjects and in the ICS group there was 195 events in 4037 subjects. (2412). Looking at these numbers there was no statistical difference among the two groups, so increased fractures were not the result of ICS use.
Of note the studies did reveal that six month or greater use of ICS therapy did slow the rate of decline and therefore improve the quality of life of the COPD patients as measured by the St. George’s Respiratory Questionnaire. However different quality of life measurements were also used in all eleven studies (2414).
In conclusion there were many issues with this meta-analysis. First, multiple studies were looked at, but not all studies were used to measure each outcome. This means the results are skewed based on which trial was used compared to an overall result. Secondly, different definitions were used in all the trials, so that means that the results really can not be compared to each other accurately. Finally while most studies showed quality of life improved while taking ICS therapy, we don’t really know how much and in what ways, as these were again measured differently in each
trial.
Drummond, M. B., Dasenbrook, E. C., & Pitz, M. W., Et al. (2008). Inhaled Corticosteroids in Patients With Stable Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis. Jama, 300(20), 2407-2416. doi:10.1001/jama.301.10.1024-b
In this study published in JAMA, the authors looked at eleven studies on the use of inhaled corticosteroids in patients with COPD defined as a smoking- related lung disease characterized by recurrent episodes of cough, sputum production and breathlessness (Drummond, 2407). The authors of this study did no research of their own, but instead looked at other double blind, randomized, placebo controlled studies from around the world, with a restriction that the study was published, lasted longer than six months and looked at ICS use compared to a control group (2408). These were searched for using medical databases and the reference sections of studies they considered. Two reviewers independently screened …show more content…
studies for inclusion and determined study eligibility with disagreements resolved by group consensus (2408) This is where the first issue arises. The authors themselves did not do any of the testing, but only looked at other’s results. Even though these studies were randomized studies, there could still be author bias in which studies were chosen, and this could skew the results. The next issue is that while 11 studies were chosen, not every study was compared to every other study, but usually only to a few studies. Therefore the results only reflect which studies were compared to each other, not the whole group. Data used in the met-analysis included study methodology, design, intervention, and main results (2408)
The primary outcome focused on was all cause mortality one year after initiation of use of inhaled corticosteroids.
As the studies all used different inhaled steroids at different doses, all were converted to the equivalent dose of beclomethasone, with conversion disagreements again settled by consensus (2408) . This means that there again was study bias as the conversion is not an exact similar dose. Not all the studies used matched all the criteria, including placebo control, combo therapy with a long acting beta agonist (LABA) and steroid alone trials. (2409) I myself found this to be very confusing as you never know which study provided which results, and how these results were interpreted. However, no study found a statistically significant 1-year mortality benefit from ICS use as compared with placebo …show more content…
(2409-2410)
Multiple secondary outcomes were also evaluated including risk of pneumonia and fractures in people taking the ICS. The first of these secondary outcomes involved the risk of pneumonia reported in seven of the studies (2411). Those seven studies looked at 10,776 patients comprised of 5405 patients in the treatment group and 5371 patients in the control group (2411). These groups represent relatively equal size study groups of a decent size. It should be noted that 61.9% of the data came from three studies. (2411). Despite this, there seemed to be a higher incidence of pneumonia among those taking ICS therapy, per the study RR 1.34;95% CI, 1.03-1.75; P=.03 (2411), or a 34% increased risk of pneumonia (2412). Furthermore, only two of the studies had clearly defined (and different) definitions of pneumonia (2412). It should also be noted that some of the pneumonia events could have been misclassified as pneumonia when they really were COPD exacerbations. (2414)
Fracture incidence was the third parameter looked at.
Three of the studies reported fracture events. (2412). In the control group, there were 178 events among 4058 subjects and in the ICS group there was 195 events in 4037 subjects. (2412). Looking at these numbers there was no statistical difference among the two groups, so increased fractures were not the result of ICS use.
Of note the studies did reveal that six month or greater use of ICS therapy did slow the rate of decline and therefore improve the quality of life of the COPD patients as measured by the St. George’s Respiratory Questionnaire. However different quality of life measurements were also used in all eleven studies (2414).
In conclusion there were many issues with this meta-analysis. First, multiple studies were looked at, but not all studies were used to measure each outcome. This means the results are skewed based on which trial was used compared to an overall result. Secondly, different definitions were used in all the trials, so that means that the results really can not be compared to each other accurately. Finally while most studies showed quality of life improved while taking ICS therapy, we don’t really know how much and in what ways, as these were again measured differently in each
trial.
Drummond, M. B., Dasenbrook, E. C., & Pitz, M. W., Et al. (2008). Inhaled Corticosteroids in Patients With Stable Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis. Jama, 300(20), 2407-2416. doi:10.1001/jama.301.10.1024-b