Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland.
Department of General Internal & Emergency Medicine and Department of Endocrinology, Diabetology and Clinical Nutrition, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland.
Clin Endocrinol (Oxf). 2019 Sep;91(3):374-382. doi: 10.1111/cen.13907. Epub 2019 Jan 9.
Glucocorticoids have been shown to improve outcome in community-acquired pneumonia (CAP). However, glucocorticoids have potential side-effects, and treatment response may vary. It is thus crucial to select patients with high likelihood to respond favourably. In critical illness, cosyntropin testing is recommended to identify patients in need for glucocorticoids. We investigated whether cosyntropin testing predicts treatment response to glucocorticoids in CAP.
Predefined secondary analysis of a randomized controlled trial.
Hospitalized patients with CAP.
We performed 1 µg cosyntropin tests in a randomized trial comparing prednisone 50 mg for 7 days to placebo. We investigated whether subgroups based on baseline and stimulated cortisol levels responded differently to glucocorticoids with regard to time to clinical stability (TTCS) and other outcomes by inclusion of interaction terms into statistical models.
A total of 326 patients in the prednisone and 309 patients in the placebo group were evaluated. Neither basal cortisol nor a Δcortisol <250 nmol/L after stimulation nor the combination of basal cortisol and Δcortisol predicted treatment response as measured by TTCS (all P for interaction >0.05). Similarly, we found no effect modification with respect to mortality, rehospitalization, antibiotic treatment duration or CAP-related complications (all P for interaction >0.05). However, glucocorticoids had a stronger effect on shortening length of hospital stay in patients with a baseline cortisol of ≥938 nmol/L (P for interaction = 0.015).
Neither baseline nor stimulated cortisol after low-dose cosyntropin testing at a dose of 1 µg predicted glucocorticoid responsiveness in mild to moderate CAP. A treatment decision for or against adjunct glucocorticoids in CAP should not be made depending on cortisol values or cosyntropin testing results.
糖皮质激素已被证明可改善社区获得性肺炎（CAP）的预后。然而，糖皮质激素有潜在的副作用，且治疗反应可能存在差异。因此，选择极有可能产生有利反应的患者至关重要。在危重病中，建议使用促皮质素检测来识别需要糖皮质激素治疗的患者。我们研究了促皮质素检测是否可预测 CAP 患者对糖皮质激素治疗的反应。
一项随机对照试验的预设二次分析。
CAP 住院患者。
我们在一项比较泼尼松 50mg 治疗 7 天与安慰剂的随机试验中进行了 1μg 促皮质素检测。我们通过在统计模型中纳入交互项，研究了基于基线和刺激后皮质醇水平的亚组在临床稳定时间（TTCS）和其他结局方面对糖皮质激素的反应是否不同。
泼尼松组共 326 例患者，安慰剂组共 309 例患者接受了评估。刺激后基础皮质醇或皮质醇变化<250nmol/L均不能预测治疗反应（所有交互作用 P 值均>0.05），也不能预测死亡率、再住院、抗生素治疗时间或 CAP 相关并发症（所有交互作用 P 值均>0.05）。然而，在基线皮质醇≥938nmol/L的患者中，糖皮质激素对缩短住院时间的效果更强（交互作用 P 值=0.015）。
低剂量（1μg）促皮质素检测后的基础皮质醇或刺激后皮质醇均不能预测轻度至中度 CAP 患者对糖皮质激素的反应。不应根据皮质醇值或促皮质素检测结果来决定 CAP 是否使用辅助性糖皮质激素治疗。
