The Thoracic Society of Australia and New Zealand
The Thoracic Society of Australia and New Zealand (TSANZ) is the only health peak body representing a range of professions (medical specialists, scientists, researchers, academics, nurses, physiotherapists, students and others) across various disciplines within the respiratory/sleep medicine field in Australia and New Zealand. The TSANZ is a Health Promotion Charity. TSANZ is committed to serving the professional needs of its members by improving knowledge and understanding of lung disease, with the ultimate goals being to prevent respiratory illness through research and health promotion and to improve health care for people with respiratory illness.
7.
Do not use long term systemic corticosteroids for management of chronic obstructive pulmonary disease (COPD)
Despite their ongoing and frequent use, there is insufficient evidence regarding efficacy of systemic corticosteroids in the treatment of COPD without exacerbations. Well- known side-effects of this drug group are obesity, respiratory and peripheral muscle weakness, hypertension, psychiatric disorders, diabetes mellitus, osteoporosis, skin thinning and bruising. The burden of cardiovascular disease has a significant impact on all-cause mortality in COPD patients. The combination of limited efficacy and potential toxicity of the drugs, especially in the at-risk patients who tend to be older, less active and have histories of smoking, means that long term use of systemic corticosteroids in COPD is not recommended.
In the cases of the exacerbations of COPD, a 2018 systematic review from Cochrane suggests that a five-day course of oral corticosteroids is likely to be sufficient and that the likelihood that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes compared with longer courses (10 to 14 days) is low.
Supporting evidence
- Corticosteroids contribute to muscle weakness in chronic airflow obstruction. M Decramer, L M Lacquet, R Fagard, and P Rogiers American Journal of Respiratory and Critical Care Medicine Volume 150, Issue 1
- Falk JA, Minai OA, Mosenifar Z. Inhaled and systemic corticosteroids in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):506-512. doi:10.1513/pats.200707-096ET
- Adverse effects of corticosteroid therapy for COPD. A critical review. McEvoy CE1, Niewoehner DE. Chest. 1997 Mar;111(3):732-43
- McGarvey LP, John M, Anderson JA, et al Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint CommitteeThorax 2007;62:411-415.
- Adverse effects of corticosteroid therapy for COPD. A critical review. McEvoy CE1, Niewoehner DE. Chest. 1997 Mar;111(3):732-43
- Olof Selroos (2004) The place of inhaled corticosteroids in chronic obstructive pulmonary disease, Current Medical Research and Opinion, 20:10, 1579-1593, DOI: 10.1185/030079904X3708
- Optimal assessment and management of chronic obstructive pulmonary disease (COPD) N.M. Siafakas, P. Vermeire, N.B. Pride, P. Paoletti, J. Gibson, P. Howard, J.C. Yernault, M. Decramer, T. Higenbottam, D.S. Postma, J. Rees, on behalf of the Task Force Eur Respir J, 1995, 8, 1398–1420
- The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2019
- Walters JAE, Tan DJ, White CJ, Wood‐Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD006897. DOI: 10.1002/14651858.CD006897.pub4.
How this list was made
In 2018 The Royal Australasian College of Physicians worked with a Lead Fellow nominated by The Thoracic Society of Australia and New Zealand (TSANZ) to review evidence for 12 paediatric thoracic recommendations on low-value care in paediatric thoracic medicine. These recommendations were the subject of email discussions and deliberation by members of the Paediatric Special Interest Group (SIG) of the TSANZ. They were further discussed at a workshop held at a meeting of the Asia Pacific Society of Respirology in 2017, which included TSANZ members. Based on the feedback provided at this workshop and through email discussions with members of the SIG, four were removed and two of the original 12 were considered for inclusion in the final recommendations with overwhelming support. Members of the Paediatric SIG were then invited to choose three out of the remaining six through an email based poll. This served as the basis for final recommendations, which were further refined and developed through successive drafts based on the input of the Lead Fellow, the results of consultation with other specialty groups and the views of the TSANZ Board.
In 2020 TSANZ worked with RACP’s Policy & Advocacy team as part of the Evolve program to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting under the guidance of the TSANZ Central Office and members of the TSANZ Board, the list was condensed to the top-5 recommendations for reducing low-value practices in adult thoracic medicine. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest in or professional engagement with thoracic medicine.
Per usual processes, the recommendations were then consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further work and refinements by Policy & Advocacy and TSANZ, which approved these top-5 recommendations.
Related recommendations
- 1 Do not prescribe combination therapy (inhaled corticosteroids with long-acting beta2 agonist) as initial therapy in mild to moderate asthma before a trial of inhaled corticosteroids alone.
- 2 Do not prescribe antibiotics for exacerbation of asthma.
- 3 Do not use oral beta2 agonists as bronchodilators in asthma, wheeze or bronchiolitis.
- 4 For children with bronchiolitis without other co-morbidities, do not delay discharge from an inpatient admission based on oxygen saturations alone if saturations are ≥90%.
- 5 Do not delay immunisation/s based on presence of mild respiratory symptoms in the absence of fever.
- 6 Do not perform a D-Dimer in patients at high risk of pulmonary embolism
- 7 Do not use long term systemic corticosteroids for management of chronic obstructive pulmonary disease (COPD)
- 8 Do not initiate maintenance inhalers in minimally symptomatic COPD patients with a low risk of exacerbation
- 9 Do not routinely follow-up solid pulmonary nodules smaller than 6 mm detected in low- risk patients
- 10 Do not perform a serum ACE for the diagnosis or monitoring of sarcoidosis