From the Guidelines
Inhaled corticosteroids (ICS) are generally not indicated as primary therapy for COPD exacerbations in the inpatient setting. The mainstay of treatment for acute COPD exacerbations includes systemic corticosteroids (typically oral prednisone 40mg daily for 5 days or IV methylprednisolone 40-60mg daily), short-acting bronchodilators (such as albuterol 2.5mg nebulized every 4-6 hours and ipratropium 0.5mg nebulized every 4-6 hours), antibiotics if infection is suspected, and supplemental oxygen as needed. Systemic corticosteroids are preferred over inhaled corticosteroids during acute exacerbations because they work more quickly to reduce inflammation and improve airflow, as supported by the European Respiratory Society/American Thoracic Society guideline 1.
Some key points to consider in the management of COPD exacerbations include:
- The use of systemic corticosteroids, such as oral prednisone or IV methylprednisolone, to reduce inflammation and improve lung function 1
- The role of short-acting bronchodilators, like albuterol and ipratropium, in relieving bronchospasm and improving symptoms 1
- The consideration of antibiotics if there is suspicion of bacterial infection, and the use of supplemental oxygen as needed 1
- The potential benefits and risks of long-term maintenance therapy with ICS, including the reduction of exacerbations and the increased risk of pneumonia, especially in patients with severe disease 1
ICS medications like fluticasone, budesonide, or beclomethasone are more appropriate for long-term maintenance therapy after discharge, particularly in patients with frequent exacerbations or those with overlapping asthma features. The rationale is that acute exacerbations involve significant systemic inflammation requiring more immediate and potent anti-inflammatory effects than what inhaled medications can provide. However, if a patient is already on ICS as part of their outpatient regimen, it is reasonable to continue this during hospitalization alongside the acute exacerbation treatment, as suggested by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document 1.
It's also important to note that the use of ICS in COPD patients should be guided by the patient's specific needs and medical history, and that the benefits and risks of ICS therapy should be carefully weighed, as discussed in the American Journal of Respiratory and Critical Care Medicine 1.
From the Research
Inhaled Corticosteroids in COPD Exacerbation
- Inhaled corticosteroids (ICS) are indicated in chronic obstructive pulmonary disease (COPD) exacerbation in an inpatient setting, particularly when used in combination with long-acting beta(2)-agonists (LABAs) or dual bronchodilator therapy 2, 3, 4.
- The use of ICS in COPD exacerbations has been shown to reduce exacerbation rates and improve lung function, although the evidence is not uniform and may depend on the specific patient population and treatment regimen 2, 5.
- High-dose nebulized budesonide has been found to be noninferior to systemic corticosteroids in hospitalized patients with COPD exacerbations who are not critically ill, with fewer cases of hyperglycemia 5.
- However, the use of ICS in COPD patients without a history of frequent or severe exacerbations, or without concomitant asthma, is not recommended due to the risk of pneumonia and other long-term adverse events 3, 4.
Patient Selection
- Patient selection is crucial when considering the use of ICS in COPD exacerbations, with factors such as frequency and severity of exacerbations, blood eosinophil levels, and presence of concomitant asthma influencing treatment decisions 3, 4.
- The BERN acronym (Bronchiolitis, Eosinophilia, Responsiveness to bronchodilator, and Non-smoker) may be useful in identifying patients who are more likely to benefit from ICS therapy 4.