More recently, the study by Lindenauer et al examined outcomes between patients treated with high-dose IV steroids (equivalent of 120 mg-800 mg of prednisone on the first or second day of treatment) compared to low-dose oral steroids (prednisone equivalents of 20 mg-80 mg per day).12 The authors found no differences between the two groups regarding the rate of treatment failure, defined by initiation of mechanical ventilation after the second hospital day, in-hospital mortality, or readmission for COPD within 30 days of discharge. After multivariate adjustment, including the propensity for oral treatment, the low-dose oral therapy group was found to have lower risk of treatment failure, shorter LOS, and lower total hospital cost.
Despite the heterogeneity of the published data and the lack of randomized trials, the existing evidence suggests that low-dose prednisone (or equivalent) is similar in efficacy to higher doses and generally is associated with shorter hospital stays. Recognizing these benefits, guidelines do favor initiating treatment with low-dose steroids in patients admitted with AECOPD. The most recent publications from the American Thoracic Society/European Respiratory Society Task Force (ATS/ERS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Clinical Guidelines Centre in the United Kingdom, and the Canadian Thoracic Society all recommend equivalent dosing of prednisone in patients admitted with AECOPD who are able to tolerate oral intake (see Table 2).1,2,15,16
Duration. As with the dosing of systemic corticosteroids in AECOPD, the optimal duration of treatment is not well-established. National and international consensus panels vary in their recommendations, as outlined in Table 2. This may be related to the variability in length of treatment found in the literature.
Treatment durations ranging from one day to eight weeks have been studied in inpatients with AECOPD. The landmark randomized controlled trial by Niewoehner and colleagues compared two-week and eight-week courses of systemic corticosteroids and found no difference in the rates of treatment failure, which included death, need for mechanical ventilation, readmission for COPD, and intensification of pharmacologic therapy.5 Based on these results, many experts have concluded that there is no benefit to steroid courses lasting beyond two weeks.
Although improvements in outcomes have been demonstrated with corticosteroid regimens as short as three days compared with placebo, most of the randomized controlled trials have included courses of seven to 14 days.4 Given the risks of adverse events (e.g. hyperglycemia) that are associated with systemic administration of steroids, the shortest effective duration should be considered.
In both clinical practice and clinical studies, steroid regimens often include a taper. A study by Vondracek and Hemstreet found that 79% of hospital discharges for AECOPD included a tapered corticosteroid regimen.14 From a physiologic standpoint, durations of corticosteroid treatment approximately three weeks or less, regardless of dosage, should not lead to adrenal suppression.17 There also is no evidence to suggest that abrupt discontinuation of steroids leads to clinical worsening of disease, and complicated steroid tapers are a potential source of medication errors after hospital discharge.18 Furthermore, the clinical guidelines do not address the tapering of corticosteroids. Therefore, there is a lack of evidence advocating for or against the use of tapered steroid regimens in AECOPD.
Back to the Case
In addition to standard treatment modalities for AECOPD, our patient was administered oral prednisone 40 mg daily. She experienced steroid-induced hyperglycemia, which was corrected with adjustment of her insulin regimen. The patient’s pulmonary symptoms improved within 72 hours, and she was discharged home on hospital day four to complete a seven-day steroid course. At hospital discharge, she was administered influenza and pneumococcal vaccinations, and she was instructed to resume her usual insulin dosing once she finished her prednisone course.