{"id":499,"date":"2023-05-10T17:37:43","date_gmt":"2023-05-10T14:37:43","guid":{"rendered":"https:\/\/tatd.org.tr\/kritik\/?p=499"},"modified":"2024-09-11T00:38:28","modified_gmt":"2024-09-10T21:38:28","slug":"ciddi-toplum-kokenli-pnomonisi-olan-kritik-hastalarda-dusuk-doz-metilprednizolon","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/kritik\/bilimsel\/ciddi-toplum-kokenli-pnomonisi-olan-kritik-hastalarda-dusuk-doz-metilprednizolon\/","title":{"rendered":"Ciddi toplum k\u00f6kenli pn\u00f6monisi olan kritik hastalarda d\u00fc\u015f\u00fck doz metilprednizolon"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Ama\u00e7\u00a0<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Yo\u011fun bak\u0131m \u00fcnitesine kabul gerektiren ciddi toplum k\u00f6kenli pn\u00f6moni (TKP), k\u0131sa ve uzun vadeli morbidite ve mortalite ile ili\u015fkilidir.&nbsp;Uzun s\u00fcreli d\u00fc\u015f\u00fck doz metilprednizolon tedavisi pulmoner inflamasyonun reg\u00fclasyonunu ve pn\u00f6moninin klinik sonu\u00e7lar\u0131n\u0131 iyile\u015ftirece\u011fini varsayd\u0131k.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Dizayn<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00c7ift-k\u00f6r, randomize, plasebo kontroll\u00fc klinik \u00e7al\u0131\u015fma<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Y\u00f6ntemler<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kat\u0131l\u0131mc\u0131lar, metilprednizolon veya plasebo almak \u00fczere 1:1 oran\u0131nda rastgele atand\u0131;&nbsp;intraven\u00f6z 40 mg&#8217;l\u0131k bir y\u00fckleme bolusunu takiben 7 g\u00fcn boyunca 40 mg\/g\u00fcn ve 20 g\u00fcnl\u00fck tedavi k\u00fcr\u00fc s\u0131ras\u0131nda progresif azaltma uyguland\u0131.&nbsp;Randomizasyon, b\u00f6lgeye ve randomizasyon s\u0131ras\u0131nda mekanik ventilasyon (MV) ihtiyac\u0131na g\u00f6re tabakaland\u0131r\u0131lm\u0131\u015ft\u0131r.&nbsp;Sonu\u00e7lar, 60 g\u00fcnl\u00fck t\u00fcm nedenlere ba\u011fl\u0131 mortaliteden olu\u015fan birincil son noktay\u0131 ve 1 y\u0131ll\u0131k izlem s\u00fcresine kadar morbidite ve mortalite ikincil sonlan\u0131m noktalar\u0131n\u0131 i\u00e7eriyordu.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Sonu\u00e7<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Ocak 2012 ile Nisan 2016 aras\u0131nda, 42 merkezden 584 hasta analize dahil edildi.&nbsp;Metilprednizolon ve plasebo kollar\u0131 aras\u0131nda 60 g\u00fcnl\u00fck mortalite a\u00e7\u0131s\u0131ndan anlaml\u0131 bir fark bulunmad\u0131. (%16&#8217;ya kar\u015f\u0131 %18; d\u00fczeltilmi\u015f olas\u0131l\u0131k oran\u0131 0,90, %95 GA 0,57-1,40).&nbsp;Sekonder sonu\u00e7larda veya komplikasyonlarda anlaml\u0131 fark yoktu.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>G\u0130R\u0130\u015e<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pn\u00f6moni, yo\u011fun bak\u0131m \u00fcnitesine (YB\u00dc) kabul gerektiren toplum k\u00f6kenli enfeksiyonun \u00f6nde gelen nedenidir ve septik \u015fok ve akut solunum s\u0131k\u0131nt\u0131s\u0131 sendromunun (ARDS) ortak bir tetikleyicisidir .&nbsp;Hastane mortalitesi daha ya\u015fl\u0131, bakteriyemik , daha fazla komorbiditesi olan, hastane k\u00f6kenli pn\u00f6moni(HCAP) kriterlerini kar\u015f\u0131layan, mekanik ventilasyon (MV) veya vazopres\u00f6r deste\u011fi gerektiren veya hastaneden yo\u011fun bak\u0131m \u00fcnitesine transfer edilen hastalarda daha y\u00fcksektir.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Glukokortikoidler, \u015fiddetli pn\u00f6monisi olan hastalarda \u00e7ok say\u0131da randomize \u00e7al\u0131\u015fmada ara\u015ft\u0131r\u0131lm\u0131\u015ft\u0131r ancak, b\u00fcy\u00fck bir do\u011frulay\u0131c\u0131 \u00e7al\u0131\u015fma eksikti.&nbsp;The Department of Veterans Affairs (VA) kooperatif \u00c7al\u0131\u015fmas\u0131 574, \u015fiddetli TKP ile yo\u011fun bak\u0131m \u00fcnitesine kabul edilen hastalarda uzun s\u00fcreli metilprednizolon tedavisinin k\u0131sa ve uzun vadeli morbidite ve mortalite \u00fczerindeki etkinli\u011fini de\u011ferlendirdi.&nbsp;20 g\u00fcnl\u00fck d\u00fc\u015f\u00fck doz metilprednizolon tedavisinin 60 g\u00fcnl\u00fck mortaliteyi azaltaca\u011f\u0131n\u0131 ve klinik sonu\u00e7lar\u0131 iyile\u015ftirece\u011fini varsayd\u0131k.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Dahil Etme Kriterleri<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u015eiddetli pn\u00f6moni i\u00e7in bir maj\u00f6r veya \u00fc\u00e7 min\u00f6r modifiye American Thoracic Society\/Infectious Diseases Society of America (ATS\/IDSA) kriterlerini kar\u015f\u0131layan ve yo\u011fun veya orta d\u00fczeyde bak\u0131ma gerek duyan hastalar \u00e7al\u0131\u015fmaya dahil edildi.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>\u00c7al\u0131\u015fma protokol\u00fc<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kat\u0131l\u0131mc\u0131lar, metilprednizolon veya plasebo almak \u00fczere 1:1 oran\u0131nda rastgele atand\u0131. Metilprednizolon veya plasebo \u00e7ift k\u00f6r olarak verildi.&nbsp;Randomizasyon g\u00fcn\u00fcnde (0. g\u00fcn), 40 mg&#8217;l\u0131k bir intraven\u00f6z y\u00fckleme dozu verildi, ard\u0131ndan idame inf\u00fczyonu yap\u0131ld\u0131.&nbsp;Tam 20 g\u00fcnl\u00fck tedavi , 1-7. g\u00fcnlerde 40 mg\/g\u00fcn, 8-14. g\u00fcnlerde 20 mg\/g\u00fcn, 15-17. g\u00fcnlerde 12 mg\/g\u00fcn ve 18-20. g\u00fcnlerde 4 mg\/g\u00fcn&#8217;\u00fc i\u00e7ermi\u015ftir.&nbsp;\u00c7al\u0131\u015fma ilac\u0131, yo\u011fun bak\u0131mda kal\u0131\u015f s\u0131ras\u0131nda s\u00fcrekli inf\u00fczyon yoluyla verildi ve yo\u011fun bak\u0131m \u00fcnitesinden taburcu olduktan sonra intraven\u00f6z veya enteral uygulama yoluyla g\u00fcnde iki kez verildi.Her iki gruptaki kat\u0131l\u0131mc\u0131lar, konsens\u00fcs \u00f6nerilerini takiben standart bak\u0131m ald\u0131.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kat\u0131l\u0131mc\u0131lar ilk yo\u011fun bak\u0131m \u00fcnitesinde kal\u0131\u015f s\u0131ras\u0131nda 8. g\u00fcne kadar g\u00fcnl\u00fck olarak, hastaneden taburcu olurken ve 28, 60 ve 180. g\u00fcnlerde de\u011ferlendirildi. Mortalite ve yeniden hastaneye yat\u0131\u015flar i\u00e7in son 1 y\u0131ll\u0131k takip, kay\u0131tlar\u0131n g\u00f6zden ge\u00e7irilmesi yoluyla yap\u0131ld\u0131.&nbsp;Tedavinin devam\u0131ndan ba\u011f\u0131ms\u0131z olarak t\u00fcm kat\u0131l\u0131mc\u0131lar\u0131 de\u011ferlendirmeye \u00e7al\u0131\u015ft\u0131k.&nbsp;Ciddi advers olaylar (SAE&#8217;ler) i\u00e7in izleme, son takip temas\u0131na kadar devam etti.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Birincil ve \u0130kincil Sonu\u00e7lar<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Birincil sonu\u00e7, 60 g\u00fcnde t\u00fcm nedenlere ba\u011fl\u0131 \u00f6l\u00fcmd\u00fc.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u0130kincil sonu\u00e7lar \u015funlar\u0131 i\u00e7ermektedir: (1) Hastanede yat\u0131\u015f s\u0131ras\u0131nda: vazopres\u00f6re ba\u011fl\u0131 \u015fok veya ARDS&#8217;nin randomizasyon sonras\u0131 geli\u015fimi;&nbsp;8. g\u00fcne kadar \u00e7oklu organ disfonksiyon sendromu (MODS) i\u00e7ermeyen g\u00fcn say\u0131s\u0131;&nbsp;8. ve 28. g\u00fcne kadar mekanik ventilasyonsuz g\u00fcnler;&nbsp;yo\u011fun bak\u0131m ve hastanede kal\u0131\u015f s\u00fcresi;&nbsp;metilprednizolon tedavisi ile ili\u015fkili potansiyel komplikasyonlar;&nbsp;ve hastane mortalitesi;&nbsp;(2) Taburculuk sonras\u0131: randomizasyondan sonraki 180 g\u00fcn i\u00e7inde kardiyovask\u00fcler komplikasyonlar;&nbsp;28, 60 ve 180. g\u00fcnlerde ya\u015fam kalitesi ve fonksiyonel durum;&nbsp;1 y\u0131l i\u00e7inde hastanelerde yeniden yat\u0131\u015f say\u0131s\u0131 ve nedenleri;&nbsp;ciddi advers olaylar ve komplikasyonlar\u0131;&nbsp;ve 180. ve 365. g\u00fcnlerde t\u00fcm nedenlere ba\u011fl\u0131 mortalite.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">MODS, S\u0131ral\u0131 Organ Yetmezli\u011fi De\u011ferlendirmesi puan\u0131 kullan\u0131larak de\u011ferlendirildi .Sa\u011fl\u0131kla ilgili ya\u015fam kalitesi Veterans RAND 12 Madde Sa\u011fl\u0131k Anketi ile \u00f6l\u00e7\u00fclm\u00fc\u015ft\u00fcr.&nbsp;Fonksiyonel durum, G\u00fcnl\u00fck Ya\u015fam Aktiviteleri \u00d6l\u00e7e\u011fi ve Enstr\u00fcmantal G\u00fcnl\u00fck Ya\u015fam Aktiviteleri \u00d6l\u00e7e\u011fi ile \u00f6l\u00e7\u00fclm\u00fc\u015ft\u00fcr.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>SONU\u00c7LAR&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Hastalar<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Uygunluk a\u00e7\u0131s\u0131ndan de\u011ferlendirilen 3936 hastan\u0131n 584&#8217;\u00fc randomize edildi;\u00a0%70&#8217;i hastane ba\u015fvurusundan sonraki 48 saat i\u00e7inde ve %94&#8217;\u00fc 72 saat i\u00e7inde (ortalama randomizasyon s\u00fcresi, 37 saat) randomize edilmi\u015ftir.\u00a0Metilprednizolon grubuna 297 kat\u0131l\u0131mc\u0131 ve plasebo grubuna 287 kat\u0131l\u0131mc\u0131 atand\u0131 (\u015eekil\u00a0\u00a0<a href=\"https:\/\/link.springer.com\/article\/10.1007\/s00134-022-06684-3#Fig1\">1<\/a>\u00a0);\u00a0193&#8217;\u00fc (%33) randomizasyon s\u0131ras\u0131nda MV al\u0131yordu.\u00a0Toplam 382 (%65) kat\u0131l\u0131mc\u0131, hastane sunumundan sonraki 48 saat i\u00e7inde ve 513 (%88) kat\u0131l\u0131mc\u0131 72 saat i\u00e7inde (hastane sunumundan \u00e7al\u0131\u015fma tedavisinin ba\u015flat\u0131lmas\u0131na kadar ge\u00e7en medyan s\u00fcre, 40 saat) i\u00e7inde \u00e7al\u0131\u015fma tedavisine ba\u015flad\u0131.\u00a0\u00c7al\u0131\u015fma ak\u0131\u015f \u015femas\u0131,\u00a0\u00a0\u00e7al\u0131\u015fma ilac\u0131n\u0131n geri \u00e7ekilmesi ve nedenleri hakk\u0131nda da bilgi sa\u011flayan \u015eekil\u00a0l&#8217; de g\u00f6sterilmektedir.<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"https:\/\/tatd.org.tr\/0bd68474-6fad-4237-8be2-0595516eb2a2\" alt=\"\u015eekil 1\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Fig\u00fcre 1<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u0130ki tedavi grubu, demografik \u00f6zellikler ve temel hasta \u00f6zellikleri a\u00e7\u0131s\u0131ndan dengeliydi.Ortalama ya\u015f 68.8 idi.Kat\u0131l\u0131mc\u0131lar\u0131n %96s\u0131 erkek ve %83\u00fc beyaz idi.&nbsp;Hastalar\u0131n ortalama d\u00f6rt maj\u00f6r komorbiditesi vard\u0131.&nbsp;Kat\u0131l\u0131mc\u0131lar\u0131n %34\u00fc HCAP kriterlerini kar\u015f\u0131lad\u0131, %69&#8217;unda akci\u011fer grafisinde \u00e7oklu lob tutulumu, %15&#8217;inde bakteriyemi, %11&#8217;inde ARDS ve %13&#8217;\u00fcnde kay\u0131t s\u0131ras\u0131nda vazopress\u00f6re ba\u011fl\u0131 \u015fok vard\u0131.&nbsp;Solunum yolu, plevral s\u0131v\u0131, kan veya idrar \u00f6rnekleri ile 577 kat\u0131l\u0131mc\u0131n\u0131n 250&#8217;sinde (%43) pn\u00f6moniden potansiyel olarak sorumlu patojenler tespit edildi.&nbsp;\u0130zole edilen en yayg\u0131n patojenler&nbsp;<em>Staphylococcus aureus<\/em>&nbsp;(%10),&nbsp;<em>Streptococcus pneumoniae<\/em>&nbsp;(%9),&nbsp;<em>Pseudomonas aeruginosa idi.<\/em>(%3)&nbsp;<em>ve Escherichia coli<\/em>&nbsp;(%3).&nbsp;ATS\/IDSA k\u0131lavuz \u00f6nerilerine g\u00f6re kat\u0131l\u0131mc\u0131lar\u0131n %96&#8217;s\u0131nda ilk antibiyotik tedavisi yeterli bulundu (\u015eekil&nbsp;&nbsp;<a href=\"https:\/\/link.springer.com\/article\/10.1007\/s00134-022-06684-3#Fig2\">2<\/a>&nbsp;).<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"https:\/\/tatd.org.tr\/ecfda0fb-03f1-45fb-bd17-8c01365d3557\" alt=\"\u015fekil 2\" \/><\/figure>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"https:\/\/tatd.org.tr\/cd4e90f8-2022-4a36-bfe0-574ae4d8c9ce\" alt=\"figure 2\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Fig\u00fcre 2: &nbsp;Kaplan-Meier sa\u011fkal\u0131m tahminleri genel pop\u00fclasyonda (&nbsp;<strong>A<\/strong>&nbsp;), randomizasyonda mekanik ventilasyon uygulanan hastalarda (MV&#8217;deki hastalar;&nbsp;<strong>B<\/strong>&nbsp;) ve randomizasyonda mekanik ventilasyon almayan hastalarda (MV&#8217;de olmayan hastalar;&nbsp;<strong>C<\/strong>&nbsp;) g\u00f6sterilmi\u015ftir.&nbsp;.&nbsp;Her paneldeki i\u00e7 metin, ayn\u0131 verileri b\u00fcy\u00fct\u00fclm\u00fc\u015f bir y ekseninde ve 60. g\u00fcne kadar g\u00f6sterir.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Birincil Sonu\u00e7lar<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">60 g\u00fcnl\u00fck t\u00fcm nedenlere ba\u011fl\u0131 mortalitede anlaml\u0131 bir fark yoktu. Metilprednizolon grubunda %16 (%95 GA %12-21) ve plasebo grubunda %18&#8217;dir (%95 GA %14-23).&nbsp;\u00c7al\u0131\u015fma b\u00f6lgeleri aras\u0131nda tedavi etkisinde \u00f6nemli bir de\u011fi\u015fiklik bulunmad\u0131.Alt grup analizlerinde gruplar aras\u0131nda anlaml\u0131 bir fark yoktu.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>\u0130kincil Sonu\u00e7lar<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">1.Hastane i\u00e7i morbidite ve mortalite<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vazopres\u00f6re ba\u011fl\u0131 \u015fok geli\u015fimi, ARDS geli\u015fimi, 8 veya 28. g\u00fcne kadar MV&#8217;siz g\u00fcnler, yo\u011fun bak\u0131mda kal\u0131\u015f s\u00fcresi (medyan 3&#8217;e 4 g\u00fcn;&nbsp;<em>p<\/em>&nbsp;\u2009= 1.00), a\u00e7\u0131s\u0131ndan tedavi gruplar\u0131 aras\u0131nda anlaml\u0131 fark yoktu. Hastane mortalitesi (%12&#8217;ye kar\u015f\u0131 %10;&nbsp;<em>p<\/em>&nbsp;\u2009= 1.00)&nbsp;a\u00e7\u0131s\u0131ndan da anlaml\u0131 fark bulunmad\u0131.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">2.Taburculuk sonras\u0131 morbitide ve mortalite<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kardiyovask\u00fcler komplikasyonlar, ya\u015fam kalitesi, fonksiyonel durum veya yeniden hastaneye yat\u0131\u015flarda gruplar aras\u0131nda anlaml\u0131 fark yoktu.En s\u0131k tekrar hastaneye yat\u0131\u015f nedenleri pn\u00f6moni (%20), konjestif kalp yetmezli\u011fi (%18) ve kronik obstr\u00fcktif akci\u011fer hastal\u0131\u011f\u0131 (KOAH) (%17) idi.&nbsp;\u0130ki grup da benzer 1 y\u0131ll\u0131k mortaliteye (%30&#8217;a kar\u015f\u0131 %33; OR 0.88; %95 GA 0.61-1.27;&nbsp;<em>p<\/em>&nbsp;\u2009= 1.00) ve \u00f6l\u00fcme kadar ge\u00e7en s\u00fcreye (HR 0.90; %95 GA 0.66-1.22;&nbsp;<em>p<\/em>&nbsp;\u2009= 1.00 ) sahipti.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>\u00d6l\u00fcm sebebi<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">T\u00fcm \u00f6l\u00fcmler, 60 g\u00fcne kadar olan \u00f6l\u00fcmler, ilk hastaneye yat\u0131\u015f s\u0131ras\u0131ndaki \u00f6l\u00fcmler veya ilk hastaneye yat\u0131\u015ftan taburcu olduktan sonraki \u00f6l\u00fcmler i\u00e7in ani veya altta yatan \u00f6l\u00fcm nedenlerinde gruplar aras\u0131nda belirgin bir fark g\u00f6zlenmedi.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>TARTI\u015eMA<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">ESCAPE \u00e7al\u0131\u015fmas\u0131, \u015fiddetli TKP veya HCAP ile yo\u011fun bak\u0131m \u00fcnitesine kabul edilen kat\u0131l\u0131mc\u0131larda, 20 g\u00fcnl\u00fck d\u00fc\u015f\u00fck doz metilprednizolon tedavisinin, birincil sonu\u00e7 olan t\u00fcm nedenlere ba\u011fl\u0131 60 g\u00fcnl\u00fck mortaliteyi \u00f6nemli \u00f6l\u00e7\u00fcde azaltmad\u0131\u011f\u0131n\u0131 g\u00f6stermi\u015ftir.&nbsp;Randomizasyonda MV&#8217;ye ihtiya\u00e7 duyan kat\u0131l\u0131mc\u0131larda medyan MV s\u00fcresinde 3 g\u00fcnl\u00fck bir azalma g\u00f6zlemledik, ancak bu alt gruptaki k\u00fc\u00e7\u00fck \u00f6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fc, tahmin edilen fark\u0131n kesinli\u011fi ve \u00e7oklu d\u00fczeltme eksikli\u011fi g\u00f6z \u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda bu bulgunun kesinli\u011fi d\u00fc\u015f\u00fck olabilir. &nbsp;1 y\u0131ll\u0131k takip s\u0131ras\u0131nda morbidite veya mortalite sonu\u00e7lar\u0131nda veya komplikasyonlarda ba\u015fka hi\u00e7bir anlaml\u0131 farkl\u0131l\u0131k bulunmad\u0131.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Bildi\u011fimiz kadar\u0131yla, bu, yo\u011fun bak\u0131m \u00fcnitesine kabul gerektiren ciddi pn\u00f6monisi olan hastalarda ek glukokortikoidlerin etkinli\u011fini ara\u015ft\u0131ran en b\u00fcy\u00fck \u00e7al\u0131\u015fma ve hem k\u0131sa hem de uzun vadeli sonu\u00e7lar\u0131 de\u011ferlendirmek i\u00e7in tasarlanm\u0131\u015f ilk randomize kontroll\u00fc \u00e7al\u0131\u015fmad\u0131r.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u015eiddetli TKP meta-analizlerinde 30 g\u00fcnl\u00fck mortalitede g\u00f6zlenen azalman\u0131n aksine, 60 g\u00fcnl\u00fck mortalitede veya 1 y\u0131la kadar mortalitede anlaml\u0131 bir azalma bulamad\u0131k.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00c7al\u0131\u015fmam\u0131z\u0131n Eksik Noktalar\u0131;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Bu \u00e7al\u0131\u015fmada glukokortikoid uygulamas\u0131n\u0131n zamanlamas\u0131, m\u00fcdahale i\u00e7in en uygun pencereyi ka\u00e7\u0131rm\u0131\u015f olabilir.&nbsp;\u00c7al\u0131\u015fmam\u0131z hastaneye yat\u0131\u015ftan 72-96 saat sonras\u0131na kadar randomizasyona izin verdi.&nbsp;\u00c7al\u0131\u015fmaya kat\u0131lanlar\u0131n %65&#8217;i \u00e7al\u0131\u015fma tedavisini hastane yat\u0131\u015f\u0131ndan sonra 48 saat i\u00e7inde ve %88&#8217;i 72 saat i\u00e7inde ba\u015flat\u0131rken, anti-inflamatuar tedavinin ba\u015flat\u0131lmas\u0131ndaki do\u011fal gecikme, invaziv mikrobiyal patojenlere yan\u0131t olarak inflamatuar mediat\u00f6rlerin ilk zirveleri s\u0131ras\u0131nda meydana geldi.Bu durum potansiyel faydalar\u0131 azaltm\u0131\u015f olabilir.<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li>\u0130kinci olarak, 40 mg\/g\u00fcn&#8217;l\u00fck metilprednizolon dozu, optimal anti-inflamatuar yan\u0131t i\u00e7in gerekli olan glukokortikoid resept\u00f6r doygunlu\u011fu seviyesine ula\u015fmak i\u00e7in yetersiz olabilir.<\/li>\n\n\n\n<li>\u00dc\u00e7\u00fcnc\u00fcs\u00fc , \u015fiddetli TKP ile ilgili \u00f6nceki en b\u00fcy\u00fck randomize kontrol\u00fc \u00e7al\u0131\u015fma ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda, oksijenasyon indeksleri, MV ihtiyac\u0131 ve kronik pulmoner ve kardiyovask\u00fcler hastal\u0131klar gibi glukokortikoid direnci ile ili\u015fkili&nbsp;&nbsp;komorbidite y\u00fck\u00fc bizim hasta pop\u00fclasyonumuzda daha fazlayd\u0131.&nbsp;<\/li>\n\n\n\n<li>D\u00f6rd\u00fcnc\u00fcs\u00fc, kontrol grubunda g\u00f6zlenen \u00f6l\u00fcm oran\u0131, g\u00fc\u00e7 hesaplamas\u0131 i\u00e7in kullan\u0131landan \u00f6nemli \u00f6l\u00e7\u00fcde d\u00fc\u015f\u00fckt\u00fc.&nbsp;<\/li>\n\n\n\n<li>Be\u015fincisi, \u00e7al\u0131\u015fma grubumuzdaki geni\u015f aral\u0131k, muhtemelen kortikosteroidlerin heterojen bir etkiye sahip oldu\u011fu farkl\u0131 patofizyolojik s\u00fcre\u00e7leri temsil ediyordu.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">\u0130kincil ve ke\u015fif ama\u00e7l\u0131 sonu\u00e7lar i\u00e7in, medyan hastanede kal\u0131\u015f s\u00fcresindeki 1 g\u00fcnl\u00fck azalma (%95 GA &#8211; 2,3 ila 0,3 g\u00fcn) meta-analizde bildirilene benzerdi. \u00d6nceki ara\u015ft\u0131rmalar\u0131n aksine, \u015fok veya ARDS&#8217;ye ilerlemede anlaml\u0131 azalma, yeniden hastaneye yat\u0131\u015f riskinde art\u0131\u015f veya miyokard enfarkt\u00fcs\u00fc insidans\u0131nda azalma g\u00f6zlemlemedik.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00c7al\u0131\u015fmam\u0131zda daha uzun metilprednizolon tedavisi, randomizasyondan sonraki 180 g\u00fcn i\u00e7inde artan ciddi adverse olaylar veya komplikasyon riski ile ili\u015fkili de\u011fildi.&nbsp;Bu bulgular pn\u00f6moni,&nbsp;septik \u015fok ve ARDS olan YB\u00dc hastalar\u0131n\u0131n g\u00fcncellenmi\u015f meta-analizlerininkilerle uyumludur ve&nbsp;bu pop\u00fclasyonda uzun s\u00fcreli glukokortikoid tedavisinin g\u00fcvenli\u011finin alt\u0131n\u0131 \u00e7izmektedir.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Glukokortikoid tedavisine yan\u0131t, d\u00fczensiz sistemik inflamasyonun \u015fiddetinden etkilenebilir. \u015eiddetli TKP ve C-reaktif protein (CRP) d\u00fczeyleri &gt; 150 mg\/L olan hastalarda yap\u0131lan bir randomize kontrol\u00fc \u00e7al\u0131\u015fmada, metilprednizolonun tedavi ba\u015far\u0131s\u0131zl\u0131\u011f\u0131n\u0131 azaltt\u0131\u011f\u0131 bulunmu\u015ftur.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/link.springer.com\/article\/10.1007\/s00134-022-06684-3#ref-CR37\">Koronavir\u00fcs hastal\u0131\u011f\u0131 2019 (COVID-19)&nbsp;<\/a>&nbsp;ve ARDS nedeniyle \u015fiddetli pn\u00f6monide glukokortikoid faydalar\u0131n\u0131n kan\u0131t\u0131,&nbsp;bu ara\u015ft\u0131rma alan\u0131na daha fazla ilgi g\u00f6stermi\u015ftir.&nbsp;Uzat\u0131lm\u0131\u015f metilprednizolon tedavisinin g\u00fcvenli\u011fi do\u011frulanm\u0131\u015ft\u0131r. Bununla birlikte, yay\u0131nlanm\u0131\u015f protokollerde dikkate de\u011fer tedavi heterojenli\u011fi, spesifik glukokortikoid, ba\u015flama zamanlamas\u0131, dozaj, s\u00fcre, uygulama modu ve azaltma stratejisi gibi, daha tek tip bir yakla\u015f\u0131ma duyulan ihtiyac\u0131n alt\u0131n\u0131 \u00e7izer.&nbsp;Bu tedavi bile\u015fenlerinin klinik sonu\u00e7lar\u0131 ve konak yan\u0131tlar\u0131n\u0131 nas\u0131l etkiledi\u011fini netle\u015ftirmek i\u00e7in daha fazla \u00e7al\u0131\u015fmaya ihtiya\u00e7 vard\u0131r.&nbsp;Pandemi s\u0131ras\u0131nda, glukokortikoid tedavisine yan\u0131tta de\u011fi\u015fkenlik g\u00f6zlemlendi ve klinisyenlerin inflamasyon ve oksijenasyon belirte\u00e7lerine g\u00f6re dozaj ve s\u00fcreyi ayarlamas\u0131na yol a\u00e7t\u0131.&nbsp;Bu, glukokortikoid tedavisinin yeterince takdir edilmeyen bir y\u00f6n\u00fcne, (i) elde edilen kandaki ila\u00e7 seviyelerinde ve (ii) h\u00fccre i\u00e7i glukokortikoid resept\u00f6r duyarl\u0131l\u0131\u011f\u0131nda b\u00fcy\u00fck de\u011fi\u015fkenli\u011fe dikkat \u00e7ekmi\u015ftir.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Eve D\u00f6n\u00fc\u015f Mesaj\u0131<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u015eiddetli toplum k\u00f6kenli pn\u00f6moni ile hastaneye yat\u0131r\u0131lan 584 kat\u0131l\u0131mc\u0131n\u0131n yer ald\u0131\u011f\u0131 bu \u00e7ift k\u00f6r, randomize, plasebo kontroll\u00fc klinik \u00e7al\u0131\u015fmada, uzun s\u00fcreli metilprednizolon tedavisi, 60 g\u00fcnl\u00fck t\u00fcm nedenlere ba\u011fl\u0131 mortaliteyi \u00f6nemli \u00f6l\u00e7\u00fcde azaltmad\u0131 veya ilk yat\u0131\u015f s\u0131ras\u0131nda veya 1 y\u0131la kadar ikincil sonu\u00e7lar\u0131 iyile\u015ftirmedi. Komplikasyon riski kontrol grubuna benzerdi.<strong><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><\/h2>\n","protected":false},"excerpt":{"rendered":"<p>\u015eiddetli toplum k\u00f6kenli pn\u00f6moni ile hastaneye yat\u0131r\u0131lan 584 kat\u0131l\u0131mc\u0131n\u0131n yer ald\u0131\u011f\u0131 bu \u00e7ift k\u00f6r, randomize, plasebo kontroll\u00fc klinik \u00e7al\u0131\u015fmada, uzun s\u00fcreli metilprednizolon tedavisi, 60 g\u00fcnl\u00fck t\u00fcm nedenlere ba\u011fl\u0131 mortaliteyi \u00f6nemli \u00f6l\u00e7\u00fcde azaltmad\u0131 veya ilk yat\u0131\u015f s\u0131ras\u0131nda veya 1 y\u0131la kadar ikincil sonu\u00e7lar\u0131 iyile\u015ftirmedi. Komplikasyon riski kontrol grubuna benzerdi.<\/p>\n","protected":false},"author":595,"featured_media":1574,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[10043],"tags":[10027,10026],"class_list":["post-499","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-bilimsel","tag-metilprednizolon","tag-toplum-kokenli-pnomoni"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/posts\/499","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/users\/595"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/comments?post=499"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/posts\/499\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/media\/1574"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/media?parent=499"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/categories?post=499"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/kritik\/wp-json\/wp\/v2\/tags?post=499"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}