When are steroids indicated for bronchitis (Chronic Obstructive Pulmonary Disease - COPD)?

Steroids for Bronchitis (COPD)

Systemic corticosteroids should be given orally or intravenously during acute exacerbations of COPD, but should NOT be used beyond 30 days following the initial exacerbation or for long-term management of stable COPD. 1

Acute Exacerbations of COPD

Indications for Systemic Corticosteroids

• Acute exacerbations of COPD in both outpatient and inpatient settings
• Short course (7-14 days) of systemic corticosteroids is recommended 1
• Typical dosing: prednisolone 30 mg/day orally or hydrocortisone 100 mg IV if oral route not possible 1

Benefits of Systemic Corticosteroids in Acute Exacerbations

• Reduces risk of hospitalization for subsequent exacerbations within the first 30 days 1
• Improves symptoms and lung function during the acute phase
• Shortens recovery time

Timing and Duration

• Should be discontinued after the acute episode (typically 7-14 days) 1
• Not recommended beyond 30 days following the initial exacerbation 1
• Grade 1A recommendation against continuing systemic steroids beyond 30 days 1

Stable COPD Management

Inhaled Corticosteroids (ICS)

• Recommended as part of combination therapy with long-acting β-agonists for stable COPD patients 2
• More appropriate for long-term management than systemic steroids
• LABA/ICS combinations are effective in preventing acute exacerbations 1

Alternatives to Steroids for Preventing Exacerbations

1. Long-acting muscarinic antagonists (LAMAs) - more effective for cough control and exacerbation reduction than LABAs alone 2
2. LABA/LAMA combinations - superior efficacy for patients with inadequate response to monotherapy 2
3. Roflumilast - for patients with moderate to severe COPD with chronic bronchitis and history of exacerbations 1
4. Oral slow-release theophylline - can help prevent acute exacerbations 1
5. N-acetylcysteine - for patients with moderate to severe COPD and history of two or more exacerbations in previous 2 years 1
6. Long-term macrolide therapy - for patients with moderate to severe COPD who continue to have exacerbations despite optimal inhaler therapy 1

Important Caveats and Pitfalls

Risks of Systemic Corticosteroids

• Short-term risks: hyperglycemia, weight gain, insomnia 1
• Long-term risks: diabetes, hypertension, infection, osteoporosis, adrenal suppression 1, 3
• The Cochrane review found no evidence to support long-term use of oral steroids at doses less than 10-15 mg prednisolone 3

Patient Selection

• Some patients may have a better response to steroids than others
• Sputum eosinophilia (but not blood eosinophilia) may predict a favorable response to steroid therapy 4
• Consider a trial of steroids in patients with worsening symptoms, but monitor objectively for response 5

Delivery Method

• For acute exacerbations, systemic delivery (oral or IV) is preferred
• For long-term management, inhaled corticosteroids are preferred to minimize systemic side effects 2, 6
• Inhaled budesonide has been shown to reduce inflammatory markers in BAL fluid in stable COPD patients 6

Algorithm for Steroid Use in COPD

1. For Acute Exacerbations:

   • Start oral prednisolone 30 mg daily (or IV equivalent if unable to take orally)
   • Continue for 7-14 days
   • Discontinue after acute episode resolves
   • Do not continue beyond 30 days after initial exacerbation

2. For Stable COPD:

   • Do not use systemic corticosteroids
   • Consider inhaled corticosteroids as part of combination therapy with long-acting bronchodilators
   • Use alternative medications (LAMAs, LABA/LAMA combinations, roflumilast, etc.) based on patient characteristics and exacerbation history

By following these evidence-based recommendations, clinicians can optimize the benefits of corticosteroid therapy while minimizing potential harms in patients with COPD.