Letters to the Editor
Importance of Appropriate Diagnosis Before Prescribing Corticosteroids
Am Fam Physician. 2020 Jul 15;102(2):76.
Original Article: Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care
Issue Date: January 15, 2020
See additional reader comments at: https://www.aafp.org/afp/2020/0115/p89.html
To the Editor: As a researcher and family physician, I was pleased to see the article by Drs. Dvorin and Ebell reminding physicians of the importance of weighing the risks and benefits of prescribing short-term systemic corticosteroids. In the article, the authors suggest that there may be evidence for treating acute bronchitis with short-term systemic corticosteroids in the context of asthma or chronic obstructive pulmonary disease (COPD). I would like to elaborate on that statement.
In the context of asthma or COPD, acute bronchitis is likely to represent an exacerbation of asthma or COPD, which is indeed an indication for a short course of oral corticosteroids.1,2 Acute bronchitis is not an indication and is likely not the correct diagnosis when a patient has been correctly diagnosed with asthma or COPD. Some may say this is simply a difference in terminology, but it is not. The frequency and severity of asthma or COPD exacerbations are important when selecting appropriate maintenance treatment for those conditions,1,2 and calling the events acute bronchitis may lead to failure to recognize the importance of recurrent events in the context of chronic obstructive lung diseases.
In addition to correct diagnostic labeling, asthma and COPD exacerbations are often recurrent and therefore may require multiple short courses of systemic corticosteroids over one or more years, elevating the patient's risks above those experienced from a single short course. Therefore, in addition to thinking about the risks of prescribing one short-term course, consider the risks of prescribing recurrent short-term courses and periodically reevaluate the adequacy of the underlying disease treatment.
Thank you for the reminder to physicians to use systemic corticosteroids appropriately, and please use appropriate diagnostic labels when prescribing those corticosteroids.
Author disclosure: Dr. Yawn is a consultant for AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis.
1. Global Initiative for Chronic Obstructive Lung Disease; 2020. Accessed January 19, 2010. https://goldcopd.org/
2. National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. November 29, 2017. Accessed January 19, 2020. http://www.nice.org.uk/guidance/ng80
In Reply: Thank you for your thoughtful response. In our review, we chose to focus on conditions in which a clear consensus for the role of systemic corticosteroids has not been achieved (unlike asthma, COPD, and other chronic inflammatory conditions in which a clear role for steroids occurs). One of our recent publications showed a high level of inappropriate systemic steroid use for patients with acute respiratory tract infections, even after excluding patients with asthma, COPD, and other inflammatory conditions in which steroids may be indicated,1 which further highlights the importance of quality improvement in appropriate steroid use.
We agree with you that for a patient with asthma and/or COPD who presents with symptoms consistent with an exacerbation of their underlying disease process, it would be more appropriate to diagnose an exacerbation of that process as opposed to bronchitis.
Author disclosure: No relevant financial affiliations.
3. Lin KJ, Dvorin E, Kesselheim AS. Prescribing systemic steroids for acute respiratory tract infections in United States outpatient settings: a nationwide population-based cohort study. PLoS Med. 2020;17(3):e1003058.
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