Journal article

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Corticosteroid use is not associated with improved outcomes in acute exacerbation of IPF

Author(s): Farrand E, Vittinghoff E, Ley B et al

Respirology 2019; doi: 10.1111/resp.13753

Interstitial lung diseases
General respiratory patient care

Digest Author(s): Stylianos Loukides, e-Learning Director / 12 January, 2020

This retrospective study aimed to determine the impact of corticosteroid therapy on in-hospital mortality in acute exacerbation (AE)- IPF patients. AE-IPF subjects were retrospectively identified in the UCSF medical centre's electronic health records from 1 January 2010 to 1 August 2018 using a code-based algorithm followed by case validation. The relationship between corticosteroid treatment and in-hospital mortality was assessed using a Cox model and a propensity score to control for confounding by indication. Secondary outcomes included hospital readmissions and overall survival. The study finally assessed 82 patients. 37 on steroids and 45 steroid naive. Considering the subjects characteristics patients who received Cs had lower values of FVC, and lower values of DLCO .

The main findings of the study are summarized as following: AE-IPF subjects treated with corticosteroids were more likely to require ICU level care and mechanical ventilation. There was no statistically significant association between corticosteroid treatment and in-hospital mortality (propensity score weighted, adjusted HR: 1.31; 95% CI: 0.26-6.55; P = 0.74). Overall survival was reduced in AE-IPF subjects receiving corticosteroids (HR: 6.17; 95% CI: 1.35-28.14; P = 0.019).

The authors finally concluded that Cs use failed to improve outcomes in IPF patients admitted to the hospital with acute exacerbation. Furthermore, corticosteroid use was not associated with improved discharge disposition or short-term hospital readmission rates, but was independently associated with reduced overall survival following an exacerbation.

Comments.

First and most important we need a randomized controlled trial in order to confirm the above observations. The second approach is to identify whether the current anti fibrotic treatments may modify the above results either in terms of reducing exacerbations or/and by changing the underlying inflammatory process. The other approach is to establish a non steroid protocol consisting of immediate cessation of any anti-fibrotic treatment and initiating the best supportive care [broad-spectrum antimicrobials and thorough evaluation to detect reversible causes of deterioration like pulmonary embolism or congestive heart failure].