What is the recommended prednisone (corticosteroid) taper regimen for severe Chronic Obstructive Pulmonary Disease (COPD) exacerbations over a two-week period?

Prednisone Taper Regimen for Severe COPD Exacerbations

For severe COPD exacerbations, a 5-day course of prednisone at 40 mg daily without tapering is recommended rather than a traditional two-week taper, based on high-quality evidence. 1

Current Recommendations for Systemic Corticosteroids in COPD Exacerbations

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines strongly recommend:

• 5-day course of systemic glucocorticoids (Evidence A)
• Limit to ≤200 mg prednisone equivalents for the entire exacerbation course
• 40 mg of prednisone daily for 5 days without tapering 1

This shorter course is supported by high-quality evidence showing that 5-day treatment is non-inferior to 14-day treatment regarding:

• Time to next exacerbation
• Treatment failure rates
• Recovery of lung function 2, 3

Benefits of Shorter Corticosteroid Course

• Significantly reduced cumulative steroid exposure (379 mg vs 793 mg) 2
• Similar clinical outcomes compared to longer courses
• Decreased risk of steroid-related adverse effects
• No difference in time to next exacerbation within 180 days 2

Implementation in Clinical Practice

For severe COPD exacerbations:

1. Start with prednisone 40 mg daily orally
2. Continue for 5 days
3. Stop without tapering
4. Combine with short-acting bronchodilators (β2-agonists with or without anticholinergics) 1

Important Clinical Considerations

• Route of administration: Oral administration is as effective as intravenous for hospitalized patients 4
• Monitoring: Schedule follow-up within 1-2 weeks to assess response 1
• Antibiotics: Add 5-7 day course if increased sputum purulence is present 1
• Oxygen therapy: Titrate to maintain SpO2 88-92% if hypoxemia is present 1

Common Pitfalls to Avoid

1. Extended tapering regimens: Evidence does not support the traditional two-week taper; the 5-day course without taper is equally effective with less cumulative steroid exposure 2, 3

2. Underdosing: Some research suggests that doses lower than 40 mg may be associated with higher failure rates (44.4% vs 22.9% for doses >40 mg) 5

3. Prolonged steroid use: Be aware of potential adverse effects with longer courses, including:

   • Hyperglycemia
   • Osteoporosis
   • Increased infection risk
   • Muscle weakness
   • Adrenal suppression
   • Skin thinning and bruising 1

The evidence strongly supports using a 5-day course of prednisone at 40 mg daily without tapering for severe COPD exacerbations, representing a significant shift from traditional longer tapering regimens.