Association of Pulse Dose Corticosteroids With Outcomes Among Patients With Acute Exacerbations of Idiopathic Pulmonary Fibrosis.

backgroundCorticosteroids are a mainstay of treatment for acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF), but dosing practices vary. We leveraged between-hospital variation in propensity to administer pulse dose corticosteroids to determine the association between pulse dose corticosteroids and patient outcomes in AE-IPF. RESEARCH QUESTION: Do outcomes differ for hospitalized patients who recieve pulse dose corticosteroids vs low dose corticosteroids for AE-IPF? STUDY DESIGN AND

methodsWe designed an instrumental variable study informed by a target trial framework using the Premier Healthcare Database (2016-2022). We identified adults ≥ 50 years of age with AE-IPF who received a dose of IV methylprednisolone within 2 days of admission. Our exposure of interest was receipt of pulse dose methylprednisolone (≥ 250 mg); our instrument was admission to a hospital with high use of pulse dosing. We assessed association with in-hospital death/discharge to hospice and discharge home without invasive mechanical ventilation. In subgroup analyses, we tested for interaction with unit of admission (admission to ICU/intermediate care units vs ward units).

resultsWe identified 3,049 patients with AE-IPF at 177 US hospitals (pulse dose: n = 1,094; low dose: n = 1,955). Patients who received a pulse dose vs low dose had a risk difference for death/hospice of 1.2% (95% CI, -6.0% to 8.5%); for discharge home without invasive mechanical ventilation, this was 5.3% (95% CI, -2.6% to 13.1%). In subgroup analysis, receipt of pulse dosing was associated with differential risk of death/hospice by admission unit (risk difference: ICU/intermediate care: 26.3%; 95% CI, 10.1%-42.6% vs ward units: 0.1%; 95% CI, -11.1% to 11.3%;

interpretationWe observed no significant benefit or harm associated with the receipt of pulse dose corticosteroids for patients with AE-IPF. However, in the subgroup of patients admitted to ICU/intermediate care, there was an increased risk of in-hospital death/discharge to hospice. Future studies should explore the use of pulse vs low-dose corticosteroids in critically ill populations with AE-IPF.