6 September 2017

Forget steroids for LRTIs in non-asthmatics

Clinical Respiratory

A new study ends the uncertainty around using steroids for chest infections in adults without asthma, showing “conclusively” that they are useless.

To understand whether the increasing popularity of oral and inhaled steroids for acute lower respiratory tract infections was backed by evidence, the UK researchers studied the effects of a moderate dose of oral corticosteroids in a group of 400 non-asthmatic patients.

Patients were randomly allocated into one of two groups: the first received 40mg of prednisolone once daily for five days and the second a placebo.

Neither the duration of the cough nor the severity of symptoms were improved by the steroids, leading the UK authors to recommend against their use in these patients.

Melbourne infectious disease physician Professor Allen Cheng said the well-conducted study provided a “definitive” answer to the question about steroid use.

“There is not much uncertainty hanging over it anymore,” the Monash University expert said.

Patients in the study had an acute cough and at least one other lower respiratory tract symptom, but  they did not require antibiotics or have a history of chronic pulmonary disease. They had also not used asthma medication in the five years prior to the study.

Study participants then recorded the presence and severity of the symptoms each day, and recorded twice-daily peak expiratory flow for the following 28 days or until the symptoms resolved. Patients were monitored for an additional 28 days in case there were late treatment effects.

The average duration of a moderately severe cough, the primary outcome, was five days in both the treatment and the placebo groups. Similarly, there was no difference in the severity of symptoms.

“Oral and inhaled steroids are known to be highly effective in treating acute asthma, as well as infective flares of other long-term lung conditions,” study co-author and GP Professor Mike Moore said.

But after testing their effect on some of the chest infection symptoms that overlap with acute asthma, including shortness of breath, wheeze and cough with phlegm, he said they “conclusively demonstrated [steroids] are not effective in this group of patients”.

The increasing use of the oral steroids was likely a response to the growing awareness of the harms of antibiotic overprescribing, the authors said, but added that this study followed previous research showing a similar lack of evidence for inhaled corticosteroids.

As well as the lack of other tools to treat non-asthmatic patients with chest infections, Professor Cheng said the familiarity with drugs’ side effect profile was another reason they might have been viewed as an attractive option.

“[Nevertheless], there are some side effects,” he said. “So you would want there to be a pretty clear benefit if you’re going to give this to patients.”

While steroids could be safely avoided in non-asthmatic patients with lower respiratory tract infections, Professor Cheng did note that a number of patients seen by GPs would likely have undiagnosed asthma or COPD, and might still benefit from steroids.