What Corticosteroid is Most Appropriate for treating Acute Exacerbations of CoPD?

What Corticosteroid Is Most Appropriate for Treating Acute Exacerbations of COPD?

KEY Points

  • Systemic corticosteroids are recommended for patients admitted with AECOPD, with benefits including shortened recovery time, improved lung function (FEV1) and hypoxemia, prolonged time to subsequent exacerbation, and reduced rates of treatment failure and hospital length of stay.
  • Oral administration is preferred over IV as there is no difference in COPD-related treatment outcomes, with oral steroids being associated with lower cost and hospital length of stay.
  • Low-dose steroids (prednisone equivalents of ≤80 mg per day) are similar in efficacy to higher doses of corticosteroids and correspond with shorter lengths of hospital stay. A starting dose of oral prednisone 40 mg daily is consistent with the existing data and current clinical guidelines.
  • A seven- to 14-day course of treatment is appropriate for most patients with AECOPD, and there is no evidence that tapering is necessary.

Additional Reading

  • From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Global Initiative for Chronic Obstructive Lung Disease website. Available at: www.goldcopd.org/
    GuidelineItem.asp?intId=989
    .
  • American Thoracic Society/European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients with COPD, version 1.2. American Thoracic Society website. Available at: www.thoracic.org/go/copd.
  • Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: A systematic review and metaanalysis. Chest. 2008;133:756-766.

Case

A 66-year-old Caucasian female with moderate chronic obstructive pulmonary disease (COPD) (FEV1 55% predicted), obesity, hypertension, and Type 2 diabetes mellitus on insulin therapy presents to the ED with four days of increased cough productive of yellow sputum and progressive shortness of breath. Her physical exam is notable for an oxygen saturation of 87% on room air, along with diffuse expiratory wheezing with use of accessory muscles; her chest X-ray is unchanged from previous. The patient is given oxygen, nebulized bronchodilators, and one dose of IV methylprednisolone. Her symptoms do not improve significantly, and she is admitted for further management. What regimen of corticosteroids is most appropriate to treat her acute exacerbation of COPD?

Overview

COPD is the fourth-leading cause of death in the United States and continues to increase in prevalence.1 Acute exacerbations of COPD (AECOPD) contribute significantly to this high mortality rate, which approaches 40% at one year in those patients requiring mechanical support.1 An exacerbation of COPD has been defined as an acute change in a patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.2 Exacerbations commonly occur in COPD patients and often necessitate hospital admission. In fact, COPD consistently is one of the 10 most common reasons for hospitalization, with billions of dollars in associated healthcare costs.3

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