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[MEDSCAPE观点]:对于COPD患者,支气管扩张剂加倍剂量作为抗炎药物能否改善全身性感染患者预后?
2017年11月20日 研究点评, 进展交流 暂无评论

COMMENTARY

In COPD, Are Sepsis Outcomes Better When a Bronchodilator Doubles as an Anti-inflammatory?

Nicholas Gross, MD, PhD

October 26, 2017

Association of Pre-hospital Theophylline Use and Mortality in Chronic Obstructive Pulmonary Disease Patients With Sepsis

Shih YN, Chen YT, Chu H, et al

Respir Med. 2017;125:33-38

Introduction 背景

Sepsis is a life-threatening disorder, and data show that its incidence doubled from 2000 through 2008.[1] Sepsis is the most expensive disease condition in the United States, with annual hospital costs of approximately $24 billion and climbing.[2] In chronic obstructive pulmonary disease (COPD), sepsis is not uncommon and mortality is high. To address this problem, investigators in Taiwan performed a study to determine whether early use of the bronchodilator theophylline in patients with COPD and sepsis reduced mortality and other related outcomes.

全身性感染是危及生命的临床综合征,数据显示2000年至2008年间其发病率增加一倍。全身性感染是美国医疗费用最高的临床疾病,每年住院费用约240亿美金且仍在不断攀升。对于COPD患者,全身性感染并不罕见,病死率很高。为说明这一问题,台湾的研究者进行了一项研究,以确定合并全身性感染的COPD患者早期使用支气管扩张剂茶碱能否改善病死率及其他相关预后。

Study Summary 研究总结

This propensity score–matched study included over 100,000 patients with COPD, equally divided between theophylline users and nonusers. Theophylline users had used the drug or had received a prescription for the drug at least 30 days before admission to the hospital. The primary outcome was 30-day mortality after hospitalization with a sepsis diagnosis.

这项倾向性评分匹配的研究纳入了超过100,000名COPD患者,均分为使用茶碱者及未使用茶碱者。使用茶碱者在入院前使用茶碱至少30天。主要预后终点为因全身性感染住院后30天病死率。

The two groups were well balanced with respect to medication use, comorbidities, and other demographics of importance. One potential feature of interest was that systemic steroids had been used by more than 20% of patients, whereas inhaled corticosteroids had been used by only 0.6%. This feature was similar in both study groups, but it differs extremely from general practice in the United States. Also, in Taiwan, very many COPD patients were receiving maintenance theophylline, which is not typical in US practice either.

两组患者在药物使用、基础疾病以及其他重要的人口统计学指标方面无显著差异。一项重要的指标是超过20%的患者全身使用皮质激素,而仅有0.6%的患者吸入激素。上述比例在两个研究组间并无差异,但与美国的情况完全不同。而且,在台湾,很多COPD患者使用维持剂量的茶碱,这在美国也不常见。

Compared with non-theophylline users, theophylline users experienced significantly lower mortality at 30 days, 180 days, and 1 year. Their overall mortality was about 4% lower. They also experienced lower mortality risk in-hospital and lower use of mechanical ventilation. The authors suggested that the difference may be due in part to an anti-inflammatory effect of theophylline.

与未使用茶碱者相比,使用茶碱者30天、180天及1年病死率显著降低(总体病死率约降低4%)。使用茶碱者住院病死率及机械通气比例较低。作者认为,上述差异可能部分由于茶碱的抗炎症作用引起。

Viewpoint 观点

The study is interesting but has a major problem in that it is retrospective. Can one be certain that theophylline users were not different from nonusers in a way that protected them from mortality? The fact that features of the patients' demographic and clinical characteristics were quite similar supports the idea that theophylline users were not systematically different and that theophylline use and no other cause explains the better outcome of theophylline users.

研究非常有趣,但主要问题为回顾性研究。我们是否能够肯定茶碱使用者与未使用者的基线特征方面没有差异?两组患者人口统计学特征及临床特征极为相似,上述事实支持以下观点,即茶碱使用者与未使用者并无显著差异,使用茶碱而非其他原因可能解释茶碱使用者的良好预后。

The trial was conducted entirely in Taiwan, which raises the question of whether the theophylline effect applies to other ethnicities. Other studies will be required to support the present findings.

试验完全在台湾进行,这引发了茶碱疗效是否同样适用于其他种族的疑问。需要其他研究支持现有发现。

The potential action of theophylline is intriguing. Theophylline is sometimes characterized as an anti-inflammatory agent, and its anti-inflammatory action has been shown to be mediated via multiple adenosine receptors.[3] Its use in modest amounts would seem to be worthy of consideration for patients with COPD.

茶碱的作用非常有趣。有时茶碱作为抗炎药物,其抗炎作用由多种腺苷受体介导。COPD患者可以考虑适当使用茶碱。

Abstract

References

1. Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief. No. 62. June 2011. https://www.cdc.gov/nchs/data/databriefs/db62.pdf Accessed September 16, 2017.

 

2. National Institute of General Medical Sciences. Sepsis fact sheet. September 2017. https://www.nigms.nih.gov/Education/pages/factsheet_sepsis.aspx#3 Accessed September 16, 2017.

 

3. Montesinos MC, Yap JS, Desai A, Posadas I, McCrary CT, Cronstein BN. Reversal of the anti-inflammatory effects of methotrexate by the nonselective adenosine receptor antagonists theophylline and caffeine: evidence that the antiinflammatory effects of methotrexate are mediated via multiple adenosine receptors in rat adjuvant arthritis. Arthritis Rheum. 2000;43:656-663. Abstract

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