NEW YORK (Reuters Health) – Patients hospitalized with community-acquired pneumonia are no better off when treated with prednisolone, according to trial results from The Netherlands.

In fact, there’s a possibility of inflammatory rebound after initial suppression by prednisolone, according to the February 4th online report in the American Journal of Respiratory and Critical Care Medicine

Previous studies have suggested that patients with community-acquired pneumonia do better when treated with steroids, and it’s been theorized that the effect is achieved through reduction of local and systemic inflammation, lead author Dr. Dominic Snijders of Medical Center Alkmaar and colleagues note.

Their study included 213 adults (mean age, 64 years) who were randomized to receive a 7-day course of 40 mg/day of prednisolone, or placebo. Patients also received either amoxicillin or moxifloxacin.

In the intent-to-treat analysis, clinical cure rates at day 7 (80.8% in the prednisolone group and 85.3% in the placebo group) and at day 30 (66.3% vs 77.1%) were not significantly different. At day 30, 6 patients in each group had died (5.8% and 5.5%, respectively).

Length of stay, time to clinical stability, and early failure rates were also similar between groups.

Prednisolone, however, was linked with a higher risk for late failure – defined as a recurrence of signs and symptoms of pneumonia 72 hours after hospital admission following an initially good response to treatment. Specifically, the late failure rates were 19.2% with prednisolone and 9.2% with placebo (odds ratio 2.36; p = 0.04).

In support of a rebound effect, the researchers note that the prednisolone group had a faster decline in C-reactive protein (CRP) level, but only up to day 7. By day 14, mean CRP levels were 42 mg/L with prednisolone and 22 mg/L with placebo (p < 0.01). A subgroup analysis of patients with severe CAP also failed to show a beneficial effect of prednisolone. The investigators comment that because patients already on corticosteroid therapy were excluded, their findings can’t be extended to patients with chronic obstructive pulmonary disease and community-acquired pneumonia. Also, they suggest, in patients who do receive steroids, tapering “might protect…against the rebound of inflammation.” They also point out that outcomes may have been better with a higher dosage of prednisolone. While they can’t exclude a benefit in patients who are severely ill, the authors conclude that prednisolone “should not be recommended as routine adjunct treatment in community-acquired pneumonia.” The study was funded by an unrestricted grant from Astra Zeneca. Reference:
Am J Respir Crit Care Med 2010.