In our journal club we reviewed the paper, recently published in CHEST journal titled Personalized Variable vs Fixed dose Systemic corticosteroid Therapy in Hospitalized patients with Acute exacerbations of COPD (AE COPD).

Is personalized-dose corticosteroid administered according to a dozing scale more effective than fixed dose corticosteroid in hospitalized patients with AE COPD?

This study challenges the recommendations of COPD guidelines, to give all patients 30 to 40 mg per day of prednisone equivalent for treatment of AE COPD. The authors created a five factor dozing scale based on routinely collected risk factors and tested its efficacy compared with conventional fixed dose corticosteroid treatment in a prospective randomized parallel group multicenter  open label trial. 

The dosing scale was calculated based on the score calculated from type of COPD exacerbation (Anthonisen type), CAT score, previous prednisone or equivalent used in exacerbation, inflammatory markers (CRP, eosinophils), blood gas analysis. The score derived from the factors (T) was put into the formula: calculated prednisolone dose =0.5 mg x weight x (1+T).

A total of 248 patients were randomly assigned to the fixed dose group or personalized dose group. In-hospital failure of therapy was significantly lower in the personalized dose group, however medium-term failure rate (combination of in-hospital treatment failure and death or readmission because of AE COPD within 180 days of discharge), adverse event rate, hospital length of  stay, and cost were similar between the two groups. 

When the failure of treatment occurred in a personalized dose group the lower additional dose of corticosteroids and shorter duration of treatment were needed to achieve control of AE COPD. Based on subgroup analysis, personalized dozing of corticosteroid reduced the risk of failure because more patients were provided with higher initial doses of prednisone, especially> 60 mg, whereas 40 mg or less was too low in either group.

This is the first prospective trial to test whether personalized dose of systemic corticosteroid therapy may be superior to fixed dose treatment. Personalized treatment reduced the risk of in-hospital treatment failure.The benefit of personalized treatment appears to be related to high initial dose of prednisone in patients who needed it. On average 60 mg of prednisone per day may be a more appropriate fixed dose regimen. Further studies are needed to confirm the results and explore the benefits of using a dosing scale to personalize corticosteroid treatment.

Published: May 2021

For the full article, follow the link: https://doi.org/10.1016/j.chest.2021.05.024