When is prednisone (corticosteroid) indicated or contraindicated for mild respiratory issues in patients with a history (hx) of smoking, Chronic Obstructive Pulmonary Disease (COPD), asthma, or other preexisting pulmonary conditions?

From the Guidelines

Prednisone should be prescribed for mild respiratory issues in patients with a history of smoking, COPD, or asthma when there is an acute exacerbation requiring anti-inflammatory intervention, but should not be used for routine management of stable symptoms. For acute COPD exacerbations, a short course of prednisone (30-40mg daily for 5 days) is typically recommended, as it shortens recovery time, improves lung function and hypoxemia, and may reduce the risk of early relapse, treatment failure, and length of hospital stay 1. This approach is supported by the 2017 European Respiratory Society/American Thoracic Society guideline, which emphasizes the benefits of systemic corticosteroids in managing COPD exacerbations.

When considering the use of prednisone, it is essential to weigh the benefits against the potential risks, including hyperglycemia, mood changes, and increased infection susceptibility, particularly in patients with uncontrolled diabetes, active infections, or psychiatric instability. The 2015 American College of Chest Physicians and Canadian Thoracic Society guideline recommends against using systemic corticosteroids solely to prevent hospitalization due to subsequent acute exacerbations of COPD beyond the first 30 days following the initial acute exacerbation 1.

Key considerations for the use of prednisone in patients with preexisting pulmonary conditions include:

• Acute exacerbations requiring anti-inflammatory intervention
• Short courses (5-7 days) for acute COPD or asthma exacerbations
• Avoidance in patients with uncontrolled diabetes, active infections, or psychiatric instability
• Tapering doses when treatment exceeds two weeks to prevent adrenal crisis
• Ensuring patients have appropriate inhaler therapy as their primary management strategy.

By prioritizing the use of prednisone for acute exacerbations and minimizing its use for routine management of stable symptoms, clinicians can optimize the benefits of this medication while minimizing its risks, ultimately improving morbidity, mortality, and quality of life for patients with preexisting pulmonary conditions.

From the FDA Drug Label

INDICATIONS AND USAGE ... 5 Allergic States Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment: Seasonal or perennial allergic rhinitis Bronchial asthma Contact dermatitis Atopic dermatitis Serum sickness Drug hypersensitivity reactions ... 7 Respiratory Diseases Symptomatic sarcoidosis Loeffler’s syndrome not manageable by other means Berylliosis Fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy Aspiration pneumonitis

The FDA drug label indicates that prednisone is indicated for bronchial asthma as part of the control of severe or incapacitating allergic conditions. There is no direct information in the provided drug labels regarding the use of prednisone for mild respiratory issues in patients with a history of smoking, COPD, or other preexisting pulmonary conditions. However, based on the available information, prednisone may be considered for severe or incapacitating allergic conditions, including bronchial asthma. For patients with a history of smoking, COPD, or other preexisting pulmonary conditions, the decision to use prednisone should be made on a case-by-case basis, taking into account the individual patient's condition and response to treatment 2. Contraindications for prednisone include systemic fungal infections and known hypersensitivity to components 2.

From the Research

Indications for Prednisone in Mild Respiratory Issues

• Patients with a history of smoking, Chronic Obstructive Pulmonary Disease (COPD), asthma, or other preexisting pulmonary conditions may be indicated for prednisone (corticosteroid) therapy in certain situations, such as acute exacerbations of COPD, where systemic glucocorticoids have been shown to shorten exacerbations and improve lung function 3.
• Inhaled corticosteroids (ICS) may be beneficial for patients with COPD who experience frequent exacerbations, have a history of hospitalizations for COPD, or have comorbid asthma 4.
• ICS may also be considered for patients with eosinophilic COPD phenotypes, as they may have a favorable response to treatment with ICS 4.

Contraindications for Prednisone in Mild Respiratory Issues

• Patients with mild COPD may not require prednisone therapy as a standalone treatment, as inhaled corticosteroids do not modify the natural history of COPD 5.
• The use of ICS in patients with COPD who continue to smoke cigarettes may be less effective due to altered glucocorticoid receptor functioning and other innate anti-inflammatory mechanisms in cells exposed to cigarette smoke 6.
• Long-term use of ICS is associated with an increased risk for side effects, including pneumonia and bone fractures in some patients, and should be carefully evaluated based on individual patient characteristics and recommendations in current guidelines 6.

Special Considerations

• The diagnosis of COPD should be made by spirometry, and therapy for patients with stable COPD should include a bronchodilator, either a long-acting beta2-agonist (LABA) or a long-acting muscarinic antagonist (LAMA) 3.
• For patients who continue to experience dyspnea with a single bronchodilator, dual therapy with a LABA and LAMA is appropriate, and inhaled corticosteroids can be added to LABA-LAMA therapy for patients with continued exacerbations 3.