Severe Adverse Events Are Associated with Short Courses of Oral Corticosteroids? 皮质激素长期服用有害，短期如何？
Each year, doctors prescribe courses of oral corticosteroids to three quarters of patients with chronic inflammatory disorders (1) and up to 17% of the general population (2). Most of these will be short “bursts” of 1 or 2 weeks, typically prescribed for common ailments like upper respiratory tract infections, bronchitis, skin rashes, eczema, psoriasis, urticaria, asthma, inflammatory bowel disease, and low back pain (3,4).
One in four Taiwan adults in a medical insured plan were given prescriptions for short term use of oral corticosteroids during a three year period (4).
Taiwan researchers evaluated 15 million adult patients (age range, 20–64; mean age, 38) to examine risks for severe adverse events after steroid-burst (<14-day) treatment, which prescribed for skin disorders and respiratory tract infections in 3 years period (2013-2015). Risks for gastrointestinal bleeding, sepsis, and heart failure were significantly higher during the 5 to 30 days after beginning steroid therapy than during the reference period (5–90 days before beginning steroids). Absolute risk rose by 10.3, 0.1, and 1.0 per 1000 patient-years for each of the three conditions, respectively. Risks attenuated during days 31 to 90 after therapy.
One in five American adults in a commercially insured plan were given prescriptions for short term use of oral corticosteroids during a three year period (5).
In this retrospective U.S. study, researchers used a nationwide commercial insurance claims dataset to determine the incidence of three adverse effects (sepsis, venous thromboembolism, and fracture) associated with oral corticosteroid use for <30 days by >15 million adults (age range, 18–64; mean age, 45) continuously enrolled from 2012 through 2014. Respiratory tract infections and disorders, spinal conditions, and allergies accounted for 56% of prescriptions.
Within 30 days of drug initiation, there was an increase in rates of sepsis (incidence rate ratio 5.30, 95% confidence interval 3.80 to 7.41), venous thromboembolism (3.33, 2.78 to 3.99), and fracture (1.87, 1.69 to 2.07), which diminished over the subsequent 31-90 days.
These studies specifically showed increased rates of sepsis, heart attack, stroke, gastrointestinal (GI) bleeding, venous thromboembolism, and fracture among patients receiving oral corticosteroids for fewer than 30 days.
we commonly use short corticosteroid “bursts” for minor ailments despite a lack of evidence for meaningful benefit. The corticosteroids might provide transient symptom relief but are not essential. We are now learning that bursts as short as 3 days may increase risk for serious adverse events, even in young and healthy people.
每年医生为四分之三的慢性炎症性疾病患者和高达总人口的17％的病患开处方口服皮质类固醇。其中大多数是1或2周短剂量口服皮质类固醇激素，用于常见疾病，例如上呼吸道感染，支气管炎，皮疹，湿疹，牛皮癣，荨麻疹，哮喘，炎性肠病和腰背痛。
台湾的医疗保险数据显示，四分之一的台湾成年患者在三年内获得了短期使用口服糖皮质激素的处方。
台湾研究人员评估了260万成年患者（年龄范围20-64;平均年龄38），以检查类固醇爆裂（<14天）治疗后严重不良事件的风险，该治疗规定了3种皮肤疾病和呼吸道感染的处方 年（2013-2015）。 在开始类固醇治疗后的5至30天内，发生胃肠道出血，败血症和心力衰竭的风险显着高于参考期间（开始类固醇之前的5至90天）。 在这三种情况下，绝对风险分别每千个患者年分别增加10.3、0.1和1.0。 在治疗后第31至90天，风险降低。
美国的商业医疗保险数据显示，五分之一的美国成年患者在三年内获得了短期使用口服糖皮质激素的处方。
在这项美国回顾性研究中，研究人员使用了全国性的商业保险理赔数据库，确定了超过150万成年人（年龄范围18 –64岁；平均45岁）获得了短期使用口服糖皮质激素的处方。呼吸道感染和疾病，脊柱疾病和过敏症占处方的56％。服药后30天内，败血症发生率（发生率比5.30，95％置信区间3.80-7.41），静脉血栓栓塞（3.33、2.78-3.99）和骨折（1.87、1.69-2.07）增加， 在停药后的31-90天内减少。
这些研究具体显示，接受口服糖皮质激素治疗少于30天的患者的败血症、心脏病发作、中风、静脉血栓栓塞和骨折发生率也会增加。尽管缺乏治疗获益的证据，我们通常给患者服用短期剂量皮质激素。皮质类固醇可能会暂时缓解症状，但不是必需的。我们现在知道，短短3天的剂量就能增加发生严重不良事件的风险，即使是年轻人和健康的人也是如此。
Reference:
- Wallace BI and Waljee AK. Burst case scenario: Why shorter may not be any better when it comes to corticosteroids. Ann Intern Med 2020 Sep 1; 173:390.
- Wallace BI, Lin P, Kamdar N, et al. Patterns of glucocorticoid pre- scribing and provider-level variation in a commercially insured inci- dent rheumatoid arthritis population: a retrospective cohort study. Semin Arthritis Rheum. 2020;50:228-236.
- Benard-Laribiere A, Pariente A, Pambrun E, et al. Prevalence and prescription patterns of oral glucocorticoids in adults: a retrospective cross-sectional and cohort analysis in France. BMJ Open. 2017;7: e015905.
- Yao TC et al. Association between oral corticosteroid bursts and severe adverse events: A nationwide population-based cohort study. Ann Intern Med 2020 Sep 1; 173:325.
- Waljee AK et al. Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ 2017 Apr 12; 357:j1415.
