What is the recommended systemic pharmacotherapy with corticosteroids (CS) for acute exacerbations of conditions like asthma or Chronic Obstructive Pulmonary Disease (COPD) in the emergency department (ED)?

Systemic Corticosteroid Therapy for Acute Exacerbations in the Emergency Department

For acute exacerbations of asthma or COPD in the emergency department, oral prednisone at 40-80 mg daily for 5 days is the recommended first-line systemic corticosteroid therapy, with intravenous administration reserved only for patients unable to take oral medications. 1, 2

Recommended Corticosteroid Regimens

For Asthma Exacerbations:

• Adults: Oral prednisone 40-80 mg/day in 1-2 divided doses until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1
• Children: Oral prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until PEF reaches 70% of predicted or personal best 1
• Duration: 5-10 days; shorter courses (5 days) are equally effective and have fewer side effects 2
• No tapering needed: For courses less than 7-10 days, no tapering is necessary 1

For COPD Exacerbations:

• Adults: Oral prednisone 40 mg daily for 5 days 2
• Purpose: To prevent hospitalization for subsequent exacerbations in the first 30 days following the initial exacerbation 1
• Duration: Short course (5 days) is recommended; longer courses do not provide additional benefits but increase adverse effects 2

Route of Administration

• Oral administration is preferred over intravenous for most patients 1, 2
• Intravenous administration (methylprednisolone) should be reserved for:
  • Patients unable to take oral medications 2
  • Patients with impaired gastrointestinal absorption 3
  • Critically ill patients requiring immediate effect 3

When IV administration is necessary, methylprednisolone can be administered at 10-40 mg depending on severity, with the dose administered over several minutes 3.

Timing and Clinical Impact

• Early administration of systemic corticosteroids in the ED is crucial, as it:
  • Speeds resolution of airflow obstruction 1
  • Reduces the rate of post-ED relapse 1, 4
  • May reduce the likelihood of hospitalization in moderate-to-severe exacerbations 1
  • Improves lung function parameters within the first 72 hours 4
  • Shortens length of hospital stay (by approximately 1.22 days) 4

Monitoring and Adverse Effects

• Blood glucose monitoring is essential, especially in patients with diabetes 2
• Common adverse effects include:
  • Hyperglycemia (significantly increased risk, OR 2.79) 4
  • Weight gain 2
  • Insomnia 2
  • Increased risk of infection 2
  • Fluid retention 2

Important Clinical Considerations

• Supplemental doses should be given to patients who regularly take corticosteroids, even if the exacerbation is mild 1
• There is no advantage for higher doses of corticosteroids in severe exacerbations 1
• Systemic corticosteroids should NOT be continued long-term beyond the acute exacerbation period 1, 2
• For patients with uncontrolled diabetes requiring corticosteroids, use a short 5-day course with close glucose monitoring 2

Adjunctive Treatments

• Inhaled β2-agonists: First-line bronchodilator therapy, administered every 20-30 minutes for the first hour 1
• Inhaled ipratropium bromide: Should be added to β2-agonist therapy in severe exacerbations 1
• Oxygen: Maintain SaO2 >90% (>95% in pregnant women and patients with heart disease) 1

Common Pitfalls to Avoid

1. Prolonged corticosteroid courses: Extending beyond 5-7 days provides no additional benefit but increases adverse effects 2
2. Unnecessary IV administration: Oral administration is equally effective when GI absorption is intact 2, 4
3. Failure to monitor glucose: Especially important in patients with diabetes 2
4. Continuing systemic corticosteroids long-term: Should only be used for the acute exacerbation 1
5. Delaying corticosteroid administration: Early administration is key to reducing hospitalization rates 1

By following these evidence-based recommendations for systemic corticosteroid therapy, clinicians can effectively manage acute exacerbations of asthma and COPD in the emergency department while minimizing adverse effects.