Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Subscriptions

Defining low-dose corticosteroid: the pendulum still oscillates

Takashi Tagami, Hiroki Matsui, Hideo Yasunaga
European Respiratory Journal 2015 46: 574-576; DOI: 10.1183/09031936.00030415
Takashi Tagami
1Dept of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
2Dept of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: t-tagami@nms.ac.jp
Hiroki Matsui
1Dept of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Hideo Yasunaga
1Dept of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • PDF
Loading

Abstract

Low-dose corticosteroids for severe CAP: further studies are required to evaluate the optimal doses and types http://ow.ly/OazFp

From the authors:

We would like to thank P.R. Mohapatra and colleagues for their comments and interest in our study [1]. We also appreciate the editors of the European Respiratory Journal for giving us the opportunity to reply. The points made by P.R. Mohapatra and colleagues regard the following: 1) the corticotrophin test, 2) the dosage of corticosteroid, and 3) comorbidities as confounding factors for the use of corticosteroid.

We agree that some patients with community-acquired pneumonia (CAP) in the present study [1] might have had adrenal insufficiency. However, we possessed no data on how many patients were responders or nonresponders to the adrenocorticotropic hormone stimulation test, which was suggested for the evaluation of septic shock patients a decade ago (grade E recommendations in the Surviving Sepsis Campaign international guidelines for management of severe sepsis and septic shock, from 2004 [2]). Meanwhile, this stimulation test is no longer recommended (rather, is recommended not to be performed) for the identification of septic shock patients who should receive corticosteroid, in the revised guidelines (grade 2B recommendations in the Surviving Sepsis Campaign guidelines from 2008 [3] and 2012 [4]). Thus, we do not necessarily agree with the opinion that “the role of corticosteroids in management of severe CAP should be based on the assessment for adrenal reserve”, as far as the recent evidence is concerned [3, 4].

Although the current guidelines for severe sepsis and septic shock recommend hydrocortisone at a dose of 200 mg·day−1 [4], the present study [1] evaluated CAP patients with mechanical ventilation. Most of the major studies and systematic review studies on CAP (with acute lung injury) have used the criteria of methylprednisolone 0.5–2.5 mg·kg−1·day−1 (or an equivalent dose of other steroids) [5–8]. Therefore, we defined low-dose corticosteroid use as intravenous infusion of methylprednisolone 0.5–2.5 mg−1·kg−1·day−1 (or an equivalent dose of dexamethasone, hydrocortisone, prednisolone or betamethasone), and any higher dose was defined as high-dose corticosteroid use in the present study [1].

We strongly agree that comorbidities may work as important confounding factors for the treatment of CAP with corticosteroid. In particular, the comorbidities would include asthma and chronic obstructive pulmonary disease (COPD), because these diseases are also often treated by corticosteroid administration. Therefore, we implemented these factors in the estimation of the propensity scores, and these confounders were well balanced after propensity score matching. Moreover, we performed an instrumental variable analysis as a confirmatory analysis of the propensity score analyses. Using hospitals' preference as an instrumental variable, we computed the differences in the 28-day mortality risk between the groups with and without corticosteroid, using a two-stage least-squares method adjusted for the patient characteristics (i.e. all variables listed in tables 1 and 2 of our study [1], including asthma and COPD). We believe that these analyses are appropriate and useful for treating measured and unmeasured confounders.

We cannot yet draw robust conclusions regarding the effect of low-dose corticosteroid for CAP patients in general, at least from our retrospective analysis [1]. We believe that further studies are required to evaluate the optimal doses and types of corticosteroids for treating CAP. Our results provide basic data for future prospective trials to lead to the “end of the story” [9] and stop the “pendulum”.

Footnotes

  • Conflict of interest: None declared.

  • Received February 23, 2015.
  • Accepted March 4, 2015.
  • Copyright ©ERS 2015

References

  1. ↵
    1. Tagami T,
    2. Matsui H,
    3. Horiguchi H, et al.
    Low-dose corticosteroid use and mortality in severe community-acquired pneumonia patients. Eur Respir J 2015; 45: 463–472.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Dellinger RP,
    2. Carlet JM,
    3. Masur H, et al.
    Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32: 858–873.
    OpenUrlCrossRefPubMedWeb of Science
  3. ↵
    1. Dellinger RP,
    2. Levy MM,
    3. Carlet JM, et al.
    Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36: 296–327.
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Dellinger RP,
    2. Levy MM,
    3. Rhodes A, et al.
    Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580–637.
    OpenUrlCrossRefPubMedWeb of Science
  5. ↵
    1. Tang BM,
    2. Craig JC,
    3. Eslick GD, et al.
    Use of corticosteroids in acute lung injury and acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care Med 2009; 37: 1594–1603.
    OpenUrlCrossRefPubMedWeb of Science
    1. Garcia-Vidal C,
    2. Calbo E,
    3. Pascual V, et al.
    Effects of systemic steroids in patients with severe community-acquired pneumonia. Eur Respir J 2007; 30: 951–956.
    OpenUrlAbstract/FREE Full Text
    1. Meijvis SC,
    2. Hardeman H,
    3. Remmelts HH, et al.
    Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial. Lancet 2011; 377: 2023–2030.
    OpenUrlCrossRefPubMedWeb of Science
  6. ↵
    1. Torres A,
    2. Sibila O,
    3. Ferrer M, et al.
    Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. JAMA 2015; 313: 677–686.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Ricard JD,
    2. Messika J
    . Low-dose corticosteroids during severe community-acquired pneumonia: end of the story. Eur Respir J 2015; 45: 305–307.
    OpenUrlAbstract/FREE Full Text
View Abstract
PreviousNext
Back to top
View this article with LENS
Vol 46 Issue 2 Table of Contents
European Respiratory Journal: 46 (2)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Defining low-dose corticosteroid: the pendulum still oscillates
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Defining low-dose corticosteroid: the pendulum still oscillates
Takashi Tagami, Hiroki Matsui, Hideo Yasunaga
European Respiratory Journal Aug 2015, 46 (2) 574-576; DOI: 10.1183/09031936.00030415

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Defining low-dose corticosteroid: the pendulum still oscillates
Takashi Tagami, Hiroki Matsui, Hideo Yasunaga
European Respiratory Journal Aug 2015, 46 (2) 574-576; DOI: 10.1183/09031936.00030415
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Footnotes
    • References
  • Info & Metrics
  • PDF

Subjects

  • Respiratory infections and tuberculosis
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Agora

  • Airway immune responses to COVID-19 vaccination in COPD patients
  • Wider access to rifapentine-based regimens is needed for TB care globally
  • Screening for PVOD in heterozygous EIF2AK4 variant carriers
Show more Agora

Correspondence

  • Clinical outcomes of bronchiectasis in India
  • Reply: Clinical outcomes of bronchiectasis in India
  • Risk factors for disease progression in fibrotic hypersensitivity pneumonitis
Show more Correspondence

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society