Corticosteroid use and mortality risk in patients with perforated colonic diverticular disease: a population-based cohort study

Abstract

BackgroundCorticosteroids are a potential risk factor for mortality in patients with perforated diverticular disease, due to blinding of disease severity, hampered wound healing or adrenal insufficiency. We examined mortality in corticosteroid users and non-users among patients with perforated diverticular disease.MethodsA cohort study based on medical databases including all patients ≥18 years in Denmark (source population 5 289 261 inhabitants) admitted to a hospital with incident perforated diverticular disease between 2005 and 2013. 7-day, 1-month, 3-month and 1-year mortality risks in corticosteroid users and non-users were calculated using the Kaplan–Meier method, and compared with Cox proportional hazard regression adjusted for age, sex and comorbidities.ResultsThe study included 4640 patients with perforated diverticular disease. Of these, 3743 (80.7%) had not used corticosteroids in the year before admission and 725 (15.6%) had been exposed to systemic corticosteroid treatment. The remaining 172 patients had been exposed to either inhaled or intestinal acting corticosteroid therapy. Mortality risk in non-users was 4.4% after 7 days and 15.6% after 1 year. This risk was doubled for corticosteroid users who filled their last prescription during the 90 days before admission, with mortality risks ranging from 14.2% after 7 days to 47.6% after 1 year. 1-year mortality risk was even higher for corticosteroid users with a first filled prescription ≤90 days before admission: 52.5%.ConclusionsCorticosteroid use was associated with clearly increased mortality risk after perforated diverticular disease. Thus, use of corticosteroids should be regarded as an important clinical prognostic factor for mortality in patients with this condition.

AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review

“…Corticosteroid use is a risk factor for diverticulitis and can contribute to complications, including perforation and death. [26][27][28][29] This is also the case for other forms of immunosuppression, such as chemotherapy and the regimens used for organ transplantation, although the risks are less well-defined. 28 Patients with an impaired immune system and diverticulitis can present with milder signs and symptoms compared with an immunocompetent patient.…”

Management of colonic diverticulitis

“…A different meta-analysis of five studies reported that corticosteroid use was associated with increased odds of diverticulitis with perforation (odds ratio 9.1, 3.5 to 23.6) compared with no use 51. In a population based study, corticosteroid use was associated with increased mortality risk in patients with complicated diverticulitis compared with no corticosteroid use (hazard ratio for chronic use at one year 1.74, 1.42 to 2.14) 53…”

“…6838486 The goal of surgery in this population is to prevent complicated recurrence. Patients who are immunosuppressed have an increased risk of complicated diverticulitis and an increased risk of death from perforated diverticulitis 5153. Unfortunately, evidence on prognosis after successful non-operative management of diverticulitis in patients who are immunocompromised is limited.…”

“…Patients who are immunosuppressed have an increased risk of death from diverticulitis compared with patients who are immunocompetent 53. Evidence by immunosuppression type is limited…”

Current and Evolving Concepts on the Pathogenesis of Diverticular Disease

“…Medical therapy can also play a role as a risk factor for DD occurrence. Use of oral corticosteroids, opiate analgesics, and non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with complicated diverticulitis [64,[69][70][71]. It is thought that NSAIDs induce mucosal damage through the reduction of prostaglandin synthesis [70], while the mechanism by which steroids and opioids cause complicated diverticulitis is less understood.…”