Postnatal use of glucocorticoids in bronchopulmonary dysplasia
- Ann R Stark, MD
Ann R Stark, MD
- Professor of Pediatrics
- Vanderbilt University School of Medicine
- Eric C Eichenwald, MD
Eric C Eichenwald, MD
- Professor of Pediatrics
- Perelman School of Medicine, University of Pennsylvania
Clinical trials have shown that postnatal glucocorticoid therapy administered systemically improves short-term lung function and outcome of infants with established bronchopulmonary dysplasia (BPD), and reduces the risk of BPD in high-risk preterm infants. However, systemic glucocorticoid administration (primarily dexamethasone) is associated with serious adverse effects. As a result, currently available evidence suggests that the potential benefits of routine administration of postnatal glucocorticoids are outweighed by its short- and long-term complications. (See "Pathogenesis and clinical features of bronchopulmonary dysplasia", section on 'Epidemiology'.)
The use of postnatal glucocorticoid therapy, including its complications in preterm infants for prevention or treatment BPD, will be reviewed here. The overall prevention and treatment of BPD are discussed separately. (See "Prevention of bronchopulmonary dysplasia" and "Management of bronchopulmonary dysplasia".)
Postnatal glucocorticoid administration is an area of intense clinical interest because of the desire to reduce the incidence and severity of bronchopulmonary dysplasia (BPD) (table 1). Despite numerous studies, however, it remains difficult to determine if a subset of infants exists in which the benefits of postnatal glucocorticoid therapy outweigh its risks, due in part to difficulties in interpreting the data because of numerous methodologic issues.
These issues include variations in the preparation of glucocorticoid used, the dosing and timing of administration, length of therapy, and the open label use of glucocorticoids in patients in control groups, as well as limited data on long-term neurodevelopmental outcome. Open label use is defined as the use of prescribed glucocorticoids by clinicians, in addition to the administration of the masked study drug. As a result, patients in the placebo group sometimes received glucocorticoids, thereby minimizing differences between treatment and control groups. Because of these issues, the postnatal use of either systemic or inhaled glucocorticoids in bronchopulmonary dysplasia is a controversial and continuously evolving subject.
Efficacy — Numerous clinical trials have shown the beneficial pulmonary effects of postnatal systemic glucocorticoids in preterm infants. Two meta-analyses have divided these trials based upon the timing of administration and their focus on either prevention or treatment of established bronchopulmonary dysplasia (BPD) [1,2].
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- SYSTEMIC STEROIDS
- - Hydrocortisone
- Short-term adverse effects
- Long-term outcome
- - Reduced steroid use and BPD
- Risk/benefit of systemic therapy
- - Are there patients who would benefit from steroid therapy?
- Glucocorticoid dose
- Hydrocortisone versus dexamethasone
- Unanswered questions
- AAP guidelines
- OUR APPROACH
- INHALED GLUCOCORTICOIDS
- Prevention of BPD
- Treatment of BPD
- Our approach to inhaled steroids
- SUMMARY AND RECOMMENDATIONS