全身性類固醇治療慢性阻塞性肺疾病急性發作的最佳治療劑量

500 135

1

1

ၡāāࢋ

( COPD )

FEV1 ( Forced Expiratory Volume in 1 second ) ( PaO

)

"The Global Initiative for Chronic Obstructive Lung Disease ( GOLD )" COPD

30-40 mg prednisolone 7-10

ᙯᔣෟĈၙّܡ๫ّ۱়ঽ ( Chronic obstructive pulmonary disease, COPD )

ާّ൴ү ( Acute exacerbation ) ϩኳᙷ׽ዔ ( Corticosteroid )

၁ᙋᗁጯ ( Evidence-based medicine )

኎Ϡཌ̳Ҷ 2006 ѐέ៉гડЯ͚ঈგۆă۱ঈ ཚ̈́ঈಆ̝Ѫ˸ˠᇴࠎ͹ࢋѪ˸ࣧЯଵЩௐ˩˘

Щ

Ą COPD дέ៉α˩໐ͽ˯ˠ˾ѐޘ஽Җத ࠎ 2.48/100 ˠĂ҃ҝੰத྿ 2.2/100 ˠ

Ą

COPD ۞ଈ۰πӮՏѐާّ൴үѨᇴࡗࠎ 2 Ҍ 3 Ѩ

Ă఺ֱާّ൴үଈ۰ᅮࢋਖ਼ާ෧఍ཉٕ

۰ҝੰڼᒚĂ׎̚ొ̶ঽˠΞਕЯЧ჌ࣧЯͅᖬ ҝੰٕ۰ൺഇГˢੰĂٙᅮᗁᒚᘽۏ̈́ˠ˧໰ᜪ

݈֏

ၙّܡ๫ّ۱়ঽ ( Chronic Obstructive Pulmonary Disease, COPD ) ߏ˘჌ײӛ྽ঈ߹ܡ

๫়̝ঽĂ׎ঈ߹ܡ๫ߏซҖّͷܧԆБΞਗ਼

ّĂ˜ѣ߲ঈវٕۏኳ͔ٙ੓̝ள૱൴ۆͅᑕٙ

࡭Ą 2000 ѐд઼࡚ COPD ߏଵҖௐα̂Ѫ˸়

ঽ

Ă COPD ˵ߏέ៉ࢦࢋ়ঽ̝˘ĂֶҖ߆ੰ

ྤ໚ࠤкĄԩϠ৵ ( Antibiotics )ă͚ঈგᕖૺ጗

( Bronchodilators ) ̈́ᙷ׽ዔ ( Corticosteroid ) ߏၙ

ّܡ๫ّ۱়ঽާّ൴үॡ၆̚ޘזࢦޘঽଈ̝

ᇾ໤ڼᒚჍࠎ ABC ᒚڱ ( ABC approach )

Ă׎̚

ൺ ഇ Б ֗ ّ ᙷ ׽ ዔ ̝ ڼ ᒚ ड़ ڍ ̏ གྷ ѣ ࡁ տ ᙋ ၁

Ă่̙Ξͽᒺൺޭೇഇ֭ͷΞԼච۱Αਕ̈́Ҳ ҕউன෪Ą൒҃Бّ֗ᙷ׽ዔдCOPD ঽଈާّ൴ үڼᒚ̝౵ָ጗ณ̈́ڼᒚ͇ᇴдధкࡁտ̪̚ѣۋ ᛉĂ҃ன̫̝ᓜԖڼᒚ޽͔˵̪ѣሀቘхд

Ăּ

т੼጗ณБّ֗ᙷ׽ዔ̝ڼᒚड़ڍߏӎᐹٺҲ጗

ณĂҲ጗ณڼᒚߏӎѣྵҲ̝ઘүϡ̈́׀൴াĄώ

͛ͽ͛ᚥаᜪ̈́ଂ၁ᙋᗁጯ۞֎ޘֽଣ੅ڼᒚ COPD ঽଈާّ൴ү౵ָ̝Бّ֗ᙷ׽ዔ጗ณĄ

ၙّܡ๫ّ۱়ঽާّ൴ү̝ؠཌྷ

၆ٺCOPD ާّ൴ү۞ؠཌྷĂϫ݈Б஧ᗁ֭ࠧ

՟ѣ˘࡭۞ВᙊĄѝഇϤ Anthonisen NR ඈ೩΍

COPD ާّ൴ү̝ؠཌྷࠎ

ĈײӛಆिΐᆐĂ།ณ ᆧΐĂ།ు႙̼ᓘĄѩؠཌྷ˜඾ࢦٺাې۞ត̼Ą

ௐ˟჌ COPD ާّ൴ү̝ؠཌྷϤ઼࡚਒ටጯ

ົ American Thoracic Society ( ATS ) ̈́ለ߷ײӛ ጯົ European Respiratory Society ( ERS ) ٺ 2000 ѐ೩΍Ăؠཌྷт˭

Ĉ COPD ̝ҋ൒ঽ඀̚ঽ ˠ΍னާّײӛӧᙱĂݜမ̈́ݜ།Ă҃ѩځព۞

Լតֹܳᗁरᅮ̬ˢአፋᘽۏڼᒚĄ

ௐˬ჌ COPD ާّ൴ү̝ؠཌྷٺ 2007 ѐϤ P.Barnes ̈́ B.Celli ٙ೩΍

Ĉݜမăݜ།̈́ײӛ ӧᙱଐڶΐᆐăײӛާܳ ( ŵ24 Ѩײӛ/Տ̶ᛗ )ă

൴፵ăϨҕ஧̿੼ ( ŵ 9000 cells/dL )ă CRP ( ŵ 10 mg/dL )Ăͷ਒ొ X Ѝ՟ѣ΍னওማĄѩؠཌྷ

̝ᐹᕇߏᆧΐྵࠎމ៍۞ෞҤĄ

ᙷ׽ዔڼᒚ COPD ̝үϡ፟ᖼ

ײӛ྽൴ۆߏ COPD ۞͹ࢋপᇈĂওማٺײ ӛ྽ጨ۞൴ۆ௟ࡪѣλጥ௟ࡪă๝ّ̚Ϩҕ஧ă CD4 ă CD8T ୽͐஧Ă఺ֱ௟ࡪٙᛖٸ̝൴ۆአ

༼ۏኳт tumor necrosis factor-ɗ ( TNF-ɗ) ̈́ leukotriene B4 ( LB4 )Ăдײӛ྽൴ۆԷႊ඾ࢦࢋ

֎ҒĄ COPD ާّ൴үঽˠ།̚۞ Interleukin-6 ( IL-6 ) ፧ޘᆧΐĂ҃ާّ൴үѨᇴྵᐛᓄ۞ঽˠ

׎།୵̚ IL-6 ׶ IL-8 ̝ૄᖂ፧ޘྵ੼

ĂТॡ།

୵̚۞୽͐஧̈́๝ᅕّϨҕ஧ࢍᇴ˵ТՎ˯̿Ą ᙷ׽ዔགྷϤኑᗔ۞௟ࡪ̈́Ϡ̼౉शֽԺט൴ ۆͅᑕĂιΞͽഴ͌୽͐஧ă๝ϿࡓّϨҕ஧ă

๝ែّ஧۞߹఼Ąᙷ׽ዔົᑅטᛖٸ macrophage inflammatory protein 1-ɗ ( MIP-1 ɗ )Ă inetrcellu- lar adhesion molecule-1 ( ICAM-1 )Ă IL1~6 Ă IL8 Ă IL11~-13 ̈́ TNF-ɗĄᙷ׽ዔ౅࿅ᇴ࣎ੈ

ि็ᅍ౉श྿јԺט൴ۆड़ڍ

Ą׎̚ޝࢦࢋ۞

ߏགྷϤԺט histone acetyltransferases ( HAT ) ֭ΐ

ૻ histone deacetylases ( HDAC2 ) ۞߿ّ҃ᙯౕ൴ ۆૄЯܑனĄѩγᙷ׽ዔົ߿̼ԩ൴ۆૄЯĂͷ ΐૻෘྋົᖼᛌј൴ۆకϨኳ۞ mRNA Ą

͛ᚥຩವ̈́ෞҿ

ώ͛ᄓᐂ̝ᓜԖྏរ͛ᚥߏٺ PubMed შ৭

۞Ϥ Haynes RB ൴ण΍ֽ Clinical Queries ຩವΑ ਕ̚ᔣˢᙯᔣෟ ( copd acute exacerbation and corticosteroid ) AND (randomized controlled t r i a l [ P u b l i c a t i o n Ty p e ] O R ( r a n d o m i z e d

ܑ˘Ĉ၁ᙋᗁጯᙋፂඈ৺

ᙋፂඈ৺ ᙋፂֽ໚ ؠཌྷ

A ᐌ፟၆໰ࡁտĂ׍ѣ࠹༊ᖳಱᇴณ̝ࡁտ୉ཏ̈́ᇴፂ ᙋፂ໚ҋనࢍ։р̝ᐌ፟ᓜԖྏរ۞˘࡭

(Randomized controlled trials, RCTs, Rich body of data.). ّ൴னĂᅮણᄃࡁտঽˠᇴϫᖳಱ̝ࡁտ

B ᐌ፟၆໰ࡁտĂᇴณѣࢨ̝ࡁտ୉ཏ̈́ᇴፂ ᙋፂ໚ҋঽˠᇴณѣࢨٕѨะဥ̝ᐌ፟ᓜԖ

(Randomized controlled trials RCTs, Limited body of data.). ྏរăᐌ፟ᓜԖྏរ̝ր௚̶ژ(meta-analysis of RCT),ٕ۰ࡁտඕڍ̙˘࡭

C ܧᐌ̝፟៍၅ّࡁտ ᙋፂ໚ҋܧ၆໰ăܧᐌٕ፟۰៍၅ّࡁտ

(Nonrandomized trials. Observational studies).

D ֶፂᓜԖགྷរ̝૞छВᙊ (Panel Consensus Judgment). ᙋፂ໚ҋᓜԖགྷរ

[Title/Abstract] AND controlled[Title/Abstract]

AND trial[Title/Abstract] ) ຩವڼᒚᙷҾĂГଂ׎

̚ፄפˠᙷ۞ᓜԖྏរᐌ፟၆໰ࡁտ͛ᚥĄ૟͛

ᚥ̰टֶ׎ᙋፂֽ໚Ă̂࡭̶ј 4 ৺၁ᙋᗁጯᙋ ፂඈ৺ ( ܑ˘ )Ą

Бّ֗ᙷ׽ዔ၆ COPD ާّ൴ү۞

ڼᒚड़ڍ

д COPD ާّ൴үঽଈ˘ਠޙᛉֹϡ˾ڇٕ

ᐖਔڦडБّ֗ᙷ׽ዔ

ĂдπӮҝੰ͟ᇴăԼ ච FEV1 ̈́ԼචҲҕউ ( PaO

) ͞ࢬĂБّ֗ᙷ׽

ዔڼᒚड़ڍѣព඾ᐹٺщᇐ጗၆໰௡

Ą҃ͷ Ξഴ͌ѝഇೇ൴̈́ڼᒚεୀத

Ą

д Wood-Baker RR. ٺ 2005 ѐٙซҖ۞ፋЪ

̶ّژ ( meta-analysis ) Вќᐂ 9 ࣎ᐌ̶፟੨ྏរ ᓁВ 921 ˠ۞ࡁտĂ၆ٺ COPD ާّ൴ү̝ڼᒚ εୀத ( Β߁Ѫ˸ăঈგ̰გ೧გăЯ COPD Г ˢੰ )ĂֹϡБّ֗ᙷ׽ዔᄃщᇐ጗၆໰௡࠹ͧ

ྵ׎ odds ratio ࠎ 0.48 ( 95% CI 0.34-0.68 )ĂՏڼ ᒚ 9 ࣎ঽଈΞᔖҺ 1 ࣎ڼᒚεୀ ( 95% CI 6-14 )

Ą

੼጗ณă̚ޘ጗ณ̈́Ҳ጗ณᙷ׽ዔ

ၱൺഇăܜഇڼᒚ̝ؠཌྷ

д͛ᚥߤᙋ̚၆ٺᙷ׽ዔ۞ֹϡ጗ณ̈́ॡม ܜൺѣధк̙Т۞௡ЪĂԧࣇԯֹϡᙷ׽ዔ۞጗

ณડ̶ࠎ੼ă̚ăҲ጗ณˬ௡

Ăؠཌྷ੼጗ณᙷ

׽ዔࠎՏ͟߉χ Methylprednisolone 500 mg Ă̚

ޘ጗ณࠎՏ͟߉χ Methylprednisolone 160 mg ٕ Տ͟ 2 mg/Տ̳͝វࢦĂٕ۰Տ͟ڦड 600 mg ̝ hydrocortisone Ă҃Ҳ጗ณ݋ࠎՏ͟߉χ 40 mg ̝ Methylprednisolone ٕ۰Տ͟˾ڇ 30-60 mg ۞ prednisolone ĄҌٺᙷ׽ዔൺഇٕܜഇڼᒚĂҌ

̫إϏѣځቁ̝ॡ඀ؠཌྷĂҭߏкᇴ۞ᙷ׽ዔࡁ տ׎ڼᒚഇมࠎ 3 Ҍ 56 ͇Ą

̙Т጗ณБّ֗ᙷ׽ዔڼᒚड़ڍ̝

ͧྵၱ̒ᕘЯ৵ଣ੅

д੼጗ณᙷ׽ዔ ( ܑ˟ ) ౵̂ݭ̝ SCCOPE ( Systemic Corticosteroid in Chronic Obstructive Disease Exaceration ) ࡁտ̚

Ă͹ࢋͧྵඕڍี

ϫࠎڼᒚεୀதăѨࢋඕڍࠎҝੰ͇͟ᇴă FEV

ត̼ࣃ̱̰̈́࣎͡Ѫ˸தĄБّ֗ᙷ׽ዔڼᒚ௡

۞ 3 0 ͇̈́ 9 0 ͇ڼᒚεୀதځពҲٺщᇐ጗௡

( ௐ 30 ͇Ă 23% vs. 33% Ă P=0.04; ௐ 90 ͇Ă 37%

vs. 48% Ă P=0.04 )Ąڼᒚ௡̝ҝੰ͟ᇴព඾Ҳٺ щᇐ጗௡ ( 8.5 ͇ vs.9.7 ͇,P=0.03 )Ą FEV1 дڼᒚ

௡ซՎྵԣĂҭߏ˟ฉޢᄃщᇐ጗௡̝ FEV1 ಶ

൑ځពमளĄҌٺ੠ᖸ̱̰࣎͡Ѫ˸த׌௡̝ม

֭൑ព඾मளĄፋវ҃֏ĂБّ֗ᙷ׽ዔڼᒚΞ

଀ז̚ޘड़ৈĂ౵̂۞ڼᒚड़ڍ΍னٺ݈˟ฉĂ ࠎഇˣฉ̝ڼᒚड़ڍ֭Ϗᐹٺ˟ฉ̝ڼᒚĄ

̚ޘ጗ณБّ֗ᙷ׽ዔ ( ܑˬ ) ̝ڼᒚड़ ڍĂ Sayiner A.

ඈˠ̝ࡁտពϯ 3 ͇̈́ 10 ͇۞

ڼᒚౌਕځពԼචউঈ̶ᑅ (PaO

) ̈́ FEV1 Ą҃

ڼᒚ˩͇̝ड़ڍᐹٺ 3 ͇̝ᒚ඀ĄΩγ˘࣎ 113

࣎ঽˠ۞ᐌ፟၆໰ࡁտ

Ϻពϯ̚ޘ጗ณБّ֗

ᙷ׽ዔڼᒚΞᆧซ FEV1 ( 0.14 L vs. 0.02L Ăགྷ 6

̈ॡᙷ׽ዔĂ P Ŵ 0.05 )Ąᙷ׽ዔڼᒚੵ˞҂ณ

጗ณЯ৵Ă୬˞ྋ˾ڇᄃᐖਔڦडߏӎࠎ̒ᕘЯ

̄Ă Shortall A22 ̈́ de Jong YP

ซҖ̝ᓜԖྏរ ࡁտពϯ˾ڇᄃᐖਔڦडБّ֗ᙷ׽ዔ̝ᒚड़֭

൑मளĂޢ۰Հޙᛉֹϡ˾ڇᙷ׽ዔڼᒚ COPD

ާّ൴үĄ

ҌٺҲ጗ณБّ֗ᙷ׽ዔ ( ܑα )Ă Davies L

д COPD ާّ൴үঽˠੵᇾ໤ڼᒚ̝͚ঈგ ᕖૺ጗ăԩϠ৵׶উঈγĂΐϡ prednisolone Տ

͇ 30 mg Вڼᒚ 14 ͇Ăᙷ׽ዔڼᒚ௡̝ FEV

ᆧ ΐதځពᐹٺщᇐ጗௡ ( щᇐ጗௡ FEV

࿰ീࣃѺ

̶தϤ 25.7% ̿Ҍ 32.2%; ڼᒚ௡Ϥ 28.2% ̿Ҍ 41.5% Ă P Ŵ 0.0001 )Ăᙷ׽ዔڼᒚ௡̝ҝੰ͟ᇴ Ϻൺٺщᇐ጗௡ ( 7 ͇ vs.9 ͇Ă P=0.027 )Ąҭߏ ѩࡁտଵੵ˞જਔҕ pH ࣃ̈ٺ 7.26 ۞ COPD ާ

ّ൴үঽˠĂࣃ଀எޥ۞યᗟтѩߏӎົጱ࡭Ᏼ ᇹઐम ( Selection bias )Ąд Shawn D

̝ࡁտͽ

˾ڇ prednisolone Տ͇ 30 mg Ăڼᒚ˩͇Ă݋ڼ ᒚ௡̝ 3 0 ͇ C O P D ೋ̼ೇ൴த̈ٺщᇐ጗௡

( 27% vs.43% Ă P=0.05 )Ă FEV

Ϻ྿ព඾ซՎĂ ײӛӧᙱ̝াېԼචϺᐹٺщᇐ጗௡ ( transition- al dyspnea index score Ă 3.95 Ų 4.62 vs. 2.07 Ų 5.53,P=0.04 )ĄΩγд Maltais F

Тᇹ൴னᙷ׽ዔ ڼᒚ௡̝ FEV

ᆧΐதᐹٺщᇐ጗௡Ą

ൺഇБّ֗ᙷ׽ዔڼᒚ̝ઘүϡ

д Wood-Baker RR ̝ፋЪ̶ّژࡁտ

Ăତ

צᙷ׽ዔڼᒚ۞ঽଈͧྵ၆໰௡ѣព඾ྵ੼̝ઘ үϡ൴Ϡத ( odds ration 2.29;95% CI 1.55-3.38 )Ą ൺഇБّ֗ᙷ׽ዔڼᒚΞਕጱ࡭̝ధкઘүϡΒ ߁੼ҕᎤă੻ኳ߹εăჟৠள૱ă੼ҕᑅăϩቲ टٽ༌๋̈́˟ޘຏߖඈ

Ą఺ֱઘүϡ̚౵૱֍

۞ߏ੼ҕᎤĄ Conn H.ซҖր௚̶ّژᓜԖྏរ ពϯൺഇБّ֗ᙷ׽ዔڼᒚົൾ຋ᆧΐ˟ޘຏߖ

̝ࢲᐍĂ˵ົᆧΐާّჟৠঽត̝൴Ϡத

Ăާ

ّჟৠঽត̝൴ϠதٺՏ͟ତצ̈ٺ 40 mg pred- nisolone ڼᒚ۞ঽˠࠎ 1.3% Ă҃Տ͟ତצ pred- nisolone80 mg ڼᒚ݋ࠎ 18.4% Ăٙضдઃͤᙷ׽

ዔޢΞޝԣޭೇĄѩγБّ֗ᙷ׽ዔϺΞጱ࡭ײ ӛ҉̈́׹ᙝ҉҇൑˧Ăѩ҉ঽត׶ᙷ׽ዔ጗ณ੼

Ҳѣ࠹ᙯّ

Ą

кᇴᓜԖᗁरᄮࠎБّ֗ᙷ׽ዔटٽ͔੓བ ࡤ྽΍ҕĂд˘࣎੫၆Бّ֗ᙷ׽ዔயϠઘүϡ

۞ր௚̶ّژ

Ăќะ 9 3 ቔᐌ፟ăᗕ۠၆໰ࡁ տ͛ᚥĂᙷ׽ዔڼᒚ௡ 3335 ࣎ঽଈ̚ѣ 13 ˠ΍

னঐّ̼ሚႹĂщᇐ጗௡ 3267 ˠѣ 9 ˠ΍னঐ

ّ̼ሚႹ ( P ŵ 0.05 )Ă׎मள֭൑௚ࢍጯຍཌྷĄ COPD ާّ൴үͽ੼጗ณᙷ׽ዔڼᒚ̝׀൴

া

Ă׎੼ҕᎤ൴Ϡதព඾੼ٺщᇐ጗௡ĄҌٺ

ܑ˟Ĉ੼጗ณБّ֗ᙷ׽ዔ

ࡁտ͛ᚥ ᐌ፟၆໰ྏរ ᗕ۠ྏរ ঽଈᇴϫ Бّ֗ᙷ׽ዔ጗ณ Бّ֗ᙷ׽ዔֹϡॡม ͹ࢋ៍ീඕڍีϫ Niewoehner ߏ ߏ N=271 Solu-medrol,ᐖਔڦड 3 ͇ޢᅍഴ጗ณ ڼᒚεୀத

et al

, 1999 ௐ˘௡ 125 mg/Տ 6 ̈ॡ Вڼᒚ 8 ฉ ҝੰ͟ᇴ

( n=80 ) ڼᒚઘүϡ

ௐ˟௡ Solu-medrol, ᐖਔڦड 3 ͇ޢᅍഴ጗ณ ( n=80 ) 125 mg/Տ 6 ̈ॡ Вڼᒚ 2 ฉ ၆໰௡ 5% dextrose, ᐖڦ 3 ͇ޢֹϡщᇐ጗

( n=111 ) Տ 6 ̈ॡ

*

ڼᒚεୀத-ЇңЯ৵ጱ࡭̝Ѫ˸Ăυื೧ঈგ̰გ̈́ײӛጡֹϡĂЯ COPD ГˢੰĂٕ۰ᅮΐૻᘽۏڼᒚĄ

ܑˬĈ̚጗ณБّ֗ᙷ׽ዔ

ࡁտ͛ᚥ ᐌ፟၆໰ྏរ ᗕ۠ྏរ ঽଈᇴϫ Бّ֗ᙷ׽ዔ጗ณ Бّ֗ᙷ׽ዔֹϡॡม ͹ࢋ៍ീඕڍีϫ eBullard MJ ߏ ߏ N=113

et al

,1996 ڼᒚ௡ Hydrocortisone: 4 ͇ޢԼ˾ڇ ڼᒚ 6 ̈ॡޢ ( n=60 ) 100 mg/Տ 4 ̈ॡ prednisolone Տ͇ FEV1, PEFR

၆໰௡ 40 mg,ᜈϡ 4 ͇

( n=53 ) щᇐ጗

Sayiner A ߏ ӎ N=34

et al

,2001 ௐ˘௡ Methylprednisolone 3 ͇ޢග̟щᇐ጗ ௐ 3 ͇̈́ௐ 10 ͇ ( n=17 ) 0.5 mg/kg Տ 6 ̈ॡ ̝ FEV1,PaO2 ௐ˟௡ Methylprednisolone 3 ͇ޢᅍഴ጗ณ

( n=17 ) 0.5 mg/kg Տ 6 ̈ॡ Вڼᒚ 10 ͇

൑၆໰௡

Shortall SP ߏ ӎ N=34 Methylprednisolone: FEV1,ҝੰ͟ᇴ et al

,2002 ௐ˘௡ ˾ڇՏ 6 ̈ॡ 40 mg,

( n=19 ) ಆᆀঐεޢԼՏ͇

˾ڇ 40 mg

ௐ˟௡ ᐖਔڦडՏ 6 ̈ॡ 40 mg

( n=15 ) ಆᆀঐεޢԼՏ͇˾ڇ 40 mg

ᚑࢦ̝ຏߖ׀൴াĂЯࠎ˟ޘຏߖ҃ᅮҝੰ۰Ă ܜॡมˣฉ۞ڼᒚ ( 80 ࣎ঽଈ̚ѣ 11 ࣎ ) (80 ࣎ঽ ଈ̚ѣ 1 ࣎ ) ̈́щᇐ጗௡ ( 111 ࣎ঽଈ̚ѣ 4 ࣎ )Ă

൒҃ѩमள֭Ϗ྿௚ࢍጯព඾ຍཌྷĄ

ͽ̚ޘ጗ณБّ֗ᙷ׽ዔڼᒚ COPD ާّ൴ үĂ Sayiner A.

̝ࡁտ൴ன 17 ࣎ঽଈ̚ѣ 2 ࣎

׀൴੼ҕᎤĂѩγ֭൑൴ன׎ι׀൴াĄ Ҳ጗ณБّ֗ᙷ׽ዔᄃઘүϡ̝ᓜԖࡁտ

Ă ڼᒚ௡ѣព඾ྵ੼̝ࢴᇒᆧΐ ( P=0.003 )ăវࢦ

˯̿ ( P=0.01 ) ̈́ε্ ( P=0.001 )Ąд Maltais F

۞ࡁտĂҲ጗ณБّ֗ᙷ׽ዔڼᒚ௡ѣྵ੼̝੼

ҕᎤ൴Ϡத ( 62 ࣎ঽଈ̚ѣ 7 ࣎ )Ăщᇐ጗௡( 66

ܑαĈҲ጗ณБّ֗ᙷ׽ዔ

ࡁտ͛ᚥ ᐌ፟၆໰ྏរ ᗕ۠ྏរ ঽଈᇴϫ Бّ֗ᙷ׽ዔ጗ณ Бّ֗ᙷ׽ዔֹϡॡม ͹ࢋ៍ീඕڍีϫ

Davies L, ߏ ӎ N=56 FEV1,

et al

,1999 ၁រ௡ Prednisolone, 14͇ ҝੰ͟ᇴ

( n=29 ) ˾ڇ 30 mg/Տ͇

၆໰௡

( n=27 )

Shawn D, ߏ ߏ N=147 FEV1,COPD

et al

, 2003 ၁រ௡ Prednisone, 10͇ ೋ̼ೇ൴த

( n=74 ) ˾ڇ 40 mg/Տ͇˘Ѩ ၆໰௡

( n=73 )

Maltais F, ߏ ߏ N=128 FEV1

et al

,2002 ၁រ௡ Prednisolone, 3 ͇ޢԼ጗ณ ( n=62 ) ˾ڇ 30 mg/ 40 mg/Տ͇Ă

Տ 12 ̈ॡ x3 ͇ В 10 ͇ ၆໰௡

( n=66 )

ܑ̣Ĉ੼጗ณă̚጗ณă̈́Ҳ጗ณБّ֗ᙷ׽ዔڼᒚ OPD ާّ൴ү̝јड़

੼጗ณ/၆໰௡ ̚጗ณ/၆໰௡ Ҳ጗ณ/၆໰௡

ڼᒚεୀத 23% vs.33%,P=0.04 ( ௐ 30 ͇ ) NA

NA

37% vs.48%,P=0.04 ( ௐ 90 ͇ )

50.5 vs.54,P=0.58 ( ௐ 182 ͇ )

ҝੰ͟ᇴ ( ͇ ) 8.5/9.7͟,ព඾ᒺൺ

NA

7/9 ͟,ព඾ᒺൺ

,P=0.027

P=0.03 6/8 ͟,Ϗ྿௚ࢍຍཌྷ

FEV1Լච ( mL ) ˟ฉޢ FEV1 ֭൑ځពमள

236 vs.68,P=0.019 30 vs.16,P=0.007

ព඾Լච

( ڼᒚௐ˩͇ ), ព඾Լච

( ڼᒚௐ˩͇ ), Pao2ᆧΐ ( mmHg ) NA

21.2 vs.11.3,P Ŵ 0.01 7 Ų 14 vs.4 Ų 12, P Ŵ 0.05

ព඾Լච

( ڼᒚௐ˩͇ ) ព඾Լච

(ڼᒚௐˬ͇)

াېԼච NA

ଈ۰ҋᛇাېඈ৺, 3.95 Ų 4.62vs.2.07 Ų 5.53,P=0.04

׌௡࠰ព඾Լච

( ࿅ഭഇ۞ಆि޽ᇾ̶ᇴ )

COPDೋ̼ೇ൴த NA

NA

27% vs.43%,P=0.05,

ព඾Լච

(30͇ೇ൴த)

NA

൑ࡁտᇴፂ

࣎ঽଈ̚ѣ 0 ࣎ )Ą

ϫ݈ࡁտ̝݀ࢨ̈́Ϗֽण୕

၆ٺϫ݈ COPD ާّ൴ү۞ᓜԖྏរࡁտ̪

צࢨٺ˭Еೀᕇ ( 1 ).COPD ާّ൴ү̝ᇾ໤ؠཌྷ

̙˘Ăϫ݈Б஧ᗁ֭ࠧ՟ѣ˘࡭۞ؠཌྷĄ( 2 ).Ч ࡁտ̝͹ࢋ៍ീีϫ̙ТĂΒ߁ڼᒚεୀதăҝ

ੰ͟ᇴă FEV

̝Լតă PaO

ࣃٕ COPD ާّ൴ үೇ൴தĂЯѩЧࡁտ̝มᙱͽۡତͧྵᇴፂĄ ( 3 ).ͣ৿ᓜԖăϠ̼ٕϠநጯ˯˘࣎ᖎಏᐹ։۞

޽ᇾĂѩ޽ᇾΞ೩ֻ COPD ೋ̼ٕڼᒚޢซՎ۞

ณ̼ᇴፂĄ( 4 ).̂ొ̶ࡁտ˜ͧྵБّ֗ᙷ׽ዔ ᄃщᇐ጗̝ड़ڍĂ֭൑ۡତͧྵҲă̚ă੼̙Т

጗ณ̝ᒚड़ĂഇޞϏֽѣѩᙷ̂ݭᐌ፟ᓜԖྏ

រĄ

ඕኢ

ᕩৼБّ֗ᙷ׽ዔڼᒚ COPD ާّ൴ү̝၁ ᙋᗁጯᙋፂтܑ̱Ą

၆ٺ COPD ާّ൴ү̝ҝੰঽଈޙᛉֹϡ˾

ڇٕᐖਔڦडБّ֗ᙷ׽ዔĄаᜪᇴ࣎ᐌ፟၆໰

ࡁտĂ੼጗ณБّ֗ᙷ׽ዔڼᒚٙᒔ଀۞ৈ఍֭

̙ᐹٺҲ጗ณБّ֗ᙷ׽ዔĄܜഇ̝ڼᒚड़ڍҬ ͼ˵Ϗᐹٺൺഇ 7 Ҍ 1 4 ͇̝ڼᒚĂ׀൴াϺᐌ

඾ڼᒚഇมᆧܜ҃ᆧΐĄ

Ҍٺᙷ׽ዔ۞౵ָڼᒚ጗ณإޞϤ̂ݭᐌ፟

၆໰ᓜԖྏរۡତͧྵ੼጗ณă̚጗ณă̈́Ҳ጗

ณॡڼᒚड़ڍĂ֭ෞҤ׎׀൴া̝யϠĄ

ૄ ٺ ᒚ ड़ ă ઘ ү ϡ ᄃ ঽ ˠ щ Б ̝ ҂ ณ Ă 2 0 0 6 ѐ "The Global Initiative for Chronic

Obstructive Lung Disease ( GOLD )" ᓜԖڼᒚ޽͔

၆ COPD ާّ൴үڼᒚ̝ޙᛉт˭Ĉ˾ڇٕᐖਔ ڦडБّ֗ᙷ׽ዔజޙᛉֹϡٺ COPD ާّ൴ү

̝ҝੰঽଈ

Ąჟቁ̝ޙᛉ጗ณإϏ୻຾Ăҭ ଳϡ 7 - 1 0 ͇۞Տ͇˾ڇ˘Ѩ 3 0 - 4 0 m g p r e d - nisolone ߏѣड़ͷщБ۞Ąؼܜڼᒚഇม̙֭ਕ

଀זՀ̂ৈ఍҃ͅົᆧΐઘүϡ̝ПᐍĄ

ણ҂͛ᚥ

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ܑ̱ĈБّ֗ᙷ׽ዔڼᒚ COPD ާّ൴ү̝၁ᙋᗁጯᙋፂ

Бّ֗ᙷ׽ዔڼᒚ COPD ާّ൴ү ၁ᙋᗁጯᙋፂඈ৺

ΞԼච FEV1 ĂᒺൺπӮҝੰ͟ᇴĂΞԼචҲҕউ(PaO2) Evidence A

ޙᛉֹϡ˾ڇٕᐖਔڦडБّ֗ᙷ׽ዔٺ COPD ާّ൴ү̝ҝੰঽଈ Evidence A

Бّ֗ᙷ׽ዔڼᒚ̙ົព඾͔੓བࡤ྽΍ҕ Evidence A

੼጗ณᙷ׽ዔܜഇˣฉ̝ڼᒚड़ڍ֭Ϗᐹٺ˟ฉ̝ൺഇڼᒚ Evidence B

੼጗ณᙷ׽ዔͧҲ጗ณѣྵк۞ᚑࢦຏߖ׀൴া Evidence B

੼጗ณ׶Ҳ጗ณБّ֗ᙷ׽ዔڼᒚ௡࠰ѣྵ੼̝੼ҕᎤ൴Ϡத Evidence B

7-10 ͇۞˾ڇ 30-40 mg prednisolone ߏѣड़ͷщБ۞ Evidence C

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Optimal Dosage of Systemic Corticosteroid for COPD with Acute Exacerbation----

Evidence-Based Review

Chin-Shui Yeh, Ching-Hsiung Lin, Cheng-Hsiung Chen, and Kwo-Chuan Lin

Short term therapy of systemic corticosteroids is the standard treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD). Several prospective randomized controlled trials demonstrated the clin- ical benefits of systemic corticosteroids to patients of COPD with acute exacerbation. However, the most optimal dosage regimen of systemic corticosteroid remains controversial. Most trials compared the effects of systemic corticosteroid and placebo without directly comparing medium-, high-, and low-dose regimens. Systemic corti- costeroids improved the FEV1 (Forced Expiratory Volume in 1 second) and the partial pressure of oxygen (PaO2) significantly. The average length of stay in hospital was also shorter with the use of corticosteroid. Systemic cor- ticosteroid use is associated with several adverse effects that are dose or duration dependent. Hyperglycemia is most common side effect ranging from low to high dose of steroid. Reported rates of secondary infection did not differ significantly among the corticosteroid and placebo, but the eight-week glucocorticoid group had the high- est proportion of patients with serious infections. Based on efficacy, safety and adverse effects, the clinical guide- line of American Thoracic Society(ATS) and European Respiratory Society(ERS) recommend the low dose cor- ticosteroid regimens such as prednisone 30 to 40 mg orally once/day for 7-10 days in most patients with an acute exacerbation of COPD. ( J Intern Med Taiwan 2008; 19: 387-393 )

Division of Chest Medicine,

Department of Internal Medicine, Changhua Christian Hospital, Taiwan