What is the recommended use of corticosteroids (CS) in elderly patients with bronchitis?

From the Guidelines

Corticosteroids are generally not recommended as a routine treatment for bronchitis in elderly patients, but may be considered in cases of acute exacerbations of chronic bronchitis or COPD with significant airway inflammation or bronchospasm. For acute bronchitis, which is typically viral in origin, corticosteroids offer minimal benefit while posing significant risks, especially in the elderly population, including increased susceptibility to infections, poor glycemic control, hypertension, osteoporosis, and psychiatric disturbances 1.

In cases of acute exacerbations of chronic bronchitis or COPD, short courses of oral corticosteroids (such as prednisone 40mg daily for 5 days) may be appropriate when there are signs of significant airway inflammation or bronchospasm, as they can shorten recovery time, improve lung function and hypoxemia, and may reduce the risk of early relapse, treatment failure, and length of hospital stay 1. Inhaled corticosteroids like fluticasone or budesonide may be considered for elderly patients with recurrent bronchitis episodes or those with underlying COPD, but should be used at the lowest effective dose and with careful monitoring, as recommended by the 2010 NICE guidelines and the 2014 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document 1.

Some key points to consider when deciding to use corticosteroids in elderly patients with bronchitis include:

• The potential benefits of corticosteroids in reducing airway inflammation and improving symptoms, as outlined in the ACCP evidence-based clinical practice guidelines 1
• The potential risks of corticosteroids, including increased susceptibility to infections, poor glycemic control, hypertension, osteoporosis, and psychiatric disturbances, as highlighted in the European Respiratory Society/American Thoracic Society guideline 1
• The importance of individualizing the decision to use corticosteroids, weighing potential benefits against risks, particularly considering that elderly patients often have comorbidities and take multiple medications that may interact with corticosteroids, as recommended by the ACCP evidence-based clinical practice guidelines 1
• The need for careful monitoring and follow-up when using corticosteroids in elderly patients, as outlined in the European Respiratory Society/American Thoracic Society guideline 1

Supportive care with adequate hydration, rest, and symptom management remains the cornerstone of bronchitis treatment in the elderly, and should be used in conjunction with corticosteroids when they are prescribed, as recommended by the ACCP evidence-based clinical practice guidelines 1.

From the FDA Drug Label

Clinical studies did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy

The increased risk of diabetes mellitus, fluid retention and hypertension in elderly patients treated with corticosteroids should be considered.

The recommended use of corticosteroids in elderly patients with bronchitis is to use the lowest possible dose and start at the low end of the dosing range, considering the increased risk of diabetes mellitus, fluid retention, and hypertension.

• Dose selection should be cautious due to the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
• There is no direct information on the use of corticosteroids specifically for bronchitis in the elderly, but general precautions for corticosteroid use in this population should be considered 2.

From the Research

Recommended Use of Corticosteroids in Elderly Patients with Bronchitis

• The use of corticosteroids in elderly patients with bronchitis is not clearly defined, but they may be beneficial in certain cases 3.
• Corticosteroids have been shown to provide an important advance in the management of bronchial asthma, but their role in the therapy for chronic obstructive pulmonary disease (COPD) has not been defined clearly 3.
• There are several theoretic reasons why corticosteroids might be useful in treating COPD, including chronic bronchitis, but the majority of studies have not demonstrated a positive effect 3.
• However, individual patients have attained marked improvement with corticosteroid therapy, and an objectively monitored, finite trial of therapy with corticosteroids in the patient with COPD who has worsening symptoms is warranted 3.

Treatment of Acute Exacerbations of COPD

• Corticosteroids, antibiotics, and bronchodilators are the cornerstones of prevention and therapy for acute exacerbations of COPD, which can include chronic bronchitis 4.
• Treatment should be evidence-based and tailored to the patient's history and present needs 4.
• The use of corticosteroids in elderly patients with acute exacerbations of COPD, including those with chronic bronchitis, may be beneficial in reducing symptoms and improving outcomes 4.

Limitations of Current Evidence

• There is limited evidence on the use of corticosteroids in elderly patients with bronchitis, and more research is needed to define their role in therapy 5, 6.
• The majority of studies on COPD and chronic bronchitis have not specifically addressed the use of corticosteroids in elderly patients, and more research is needed to determine their efficacy and safety in this population 3, 4.