Steroid Dosing, Surgery Outcomes for COVID-19 Patients, and More: Highlights from 2021 Research
Drs. Frank and Grant did an outstanding job with their in-person In the Literature at SHM Converge.
Whether to use a standard or a personalized dose of corticosteroids in hospitalized patients with flares of chronic obstructive pulmonary disease (COPD), and outcomes of COVID-19 patients undergoing surgery were among the highlights in hospital medicine-related research over the past year, according to an expert review at SHM Converge.
The plenary speakers—Gaby Frank, MD, associate professor of medicine at the University of Colorado School of Medicine, Aurora, Colo., and Paul Grant, MD, clinical associate professor of medicine at the University of Michigan, Ann Arbor, Mich.—summarized literature in 11 relevant journals for the year.
Here are some of the presented summaries:
Is personalized-dose corticosteroid administered according to a dosing scale more effective than fixed-dose corticosteroid administration in hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (COPD)?
Li L, et al. Personalized Variable vs Fixed-Dose Systemic Corticosteroid Therapy in Hospitalized Patients With Acute Exacerbations of COPD: A Prospective, Multicenter, Randomized, Open-Label Clinical Trial. Chest. 2021 Nov;160(5):1660-1669.
This multi-center, prospective, randomized, open-label trial at four tertiary care hospitals in China included 248 patients who were randomized to receive a personalized dose or a fixed-dose.
The daily dose of prednisolone was 61.4 mg in the personalized group and 56.2 in the fixed group. Failure of therapy in the hospital—meaning death, need for mechanical ventilation, additional corticosteroids, aminophylline, or an upgrade in antibiotics—occurred in 10.6% of the personalized group compared to 24.4% of the fixed group. The fixed group also fared worse in terms of death or readmission for acute exacerbation of COPD (AECOPD) within 180 days of discharge, and other parameters.
Researchers found that composite failure in the personalized group was lower, at 23.4%, for those who received more than 60 mg of prednisolone per day, than the 31.3% composite failure rate for those receiving less than 60 mg per day.
The efficacy of the higher dosing raises questions about the GOLD—Global Initiative for Chronic Obstructive Lung Disease—recommendation for AECOPD, which is 40 mg per day, Dr. Frank noted.
“On average, a GOLD-recommended dose of 40 mg of prednisone may be too low, and 60 mg—maybe not personalized but a dose of 60—may be better,” she said.
What is the association between the time of elective surgery, relative to the development of COVID-19 infection, and the risk of pulmonary and other major post-operative complications?
Deng JZ, et al. The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States. Ann Surg. 2022 Feb 1;275(2):242-246.
Researchers in the U.S. reviewed data on about 5,479 patients who had one major elective surgery and who had a COVID-19 diagnosis. They included non-emergent procedures, including brain mass resection, carotid endarterectomy, total knee arthroplasty, and other surgeries. Most of the patients had mild cases of COVID-19.
Among the findings, those having surgery within four weeks of their COVID-19 diagnosis had a 480% higher risk of developing post-op pneumonia and a 208% higher risk of respiratory failure. They were also at a higher risk for other complications. Those having surgery four to eight weeks after the COVID-19 diagnosis had a 96% increased risk of post-op pneumonia. Patients undergoing surgery at least eight weeks after the diagnosis of COVID-19 had similar post-operative risk as the control group of patients who had procedures performed before a COVID diagnosis.
Total knee arthroplasty was the most common surgery done among patients who’d had a COVID-19 diagnosis within the previous four weeks—although it is the type of procedure that could safely be could put off for a bit, Dr. Frank said.
“So for all of us who do peri-op medicine, it’s important to try to recommend that elective surgery be delayed a little, after the eight weeks,” Dr. Frank said.
Do non-critically ill patients with community-acquired pneumonia (CAP) need more beta-lactam antibiotics if they are stable after three days of treatment?
Dinh A, et al. Discontinuing ß-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial. Lancet. 2021 Mar 27;397(10280):1195-1203.
This was a double-blind, randomized, placebo-controlled, non-inferiority trial at 16 hospitals in France, with 310 patients admitted for moderately severe CAP. Those who were clinically stable after 72 hours were randomized to receive a placebo or five more days of amoxicillin plus clavulanate.
The placebo group did no worse than those who were continued on treatment. At 15 days, 77% of the placebo group had been “cured,” with no fever, with resolution or improvement of respiratory symptoms, and no additional antibiotics for any reason. That compared to 68% for the beta-lactam group, which was not inferior.
Dr. Grant noted that the Infectious Disease Society of America guidelines recommend a minimum of five days of treatment—and he didn’t expressly call the recommendation into question—but he said these findings suggest that clinicians might consider a shorter course than they usually use.
“At least if you’re still doing seven, eight, or 10 days of antibiotics, certainly consider dropping down to at least five for your patients who are clinically stable early in their course,” he said.
In patients with acute myocardial infarction (MI) and anemia, is a restrictive strategy of blood transfusion non-inferior to a liberal strategy for 30-day major adverse cardiac events (MACE)?
Ducrocq G, et al. Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial. JAMA. 2021 Feb 9;325(6):552-560.
This randomized, controlled, non-inferiority trial was performed across 35 hospitals in France and Spain and included 668 patients with MI and hemoglobin between 7 and 10 g/dL.
Patients were randomized to either a “restrictive” or “liberal” strategy of transfusion. With the restrictive strategy, transfusion was triggered by an Hg of 8 or lower with a post-transfusion target of 8 to 10 g/dL. With the liberal strategy, it was triggered by an Hg of 10 or lower with a post-transfusion target of 11 g/dL or higher.
At 30 days, 11% of patients in the restrictive group reached the primary outcome of death, stroke, recurrent MI, or emergency revascularization. That compared to 14% for the liberal strategy, and the restrictive strategy was found to be statistically non-inferior, although it didn’t meet the criteria for superiority, Dr. Grant said.
“This is even more data supporting a restrictive strategy for blood transfusions,” he said. “Now we’re seeing this in patients with acute coronary syndrome. Fewer transfusions are obviously a good thing, with respect to less transfusion-related risk, and lower cost. And it couldn’t be more timely now with respect to blood-transfusion supply.”
Tom Collins is a medical writer in South Florida.