What is the rationale for using steroids in acute exacerbation of chronic obstructive pulmonary disease (COPD)?

Rationale for Using Steroids in Acute Exacerbation of COPD

Systemic corticosteroids are recommended in acute exacerbations of COPD because they improve lung function (FEV1), shorten recovery time, reduce risk of treatment failure, and decrease hospitalization duration. 1

Mechanisms of Action and Benefits

• Corticosteroids reduce airway inflammation, which is a key pathophysiological component of COPD exacerbations 1
• They specifically reduce lymphocytic inflammation in COPD airways, with potentially more pronounced effects in patients with predominant lymphocytic airway inflammation 1
• Systemic corticosteroids improve oxygenation during acute exacerbations, contributing to faster clinical improvement 1
• Treatment with systemic corticosteroids reduces the risk of treatment failure by over 50% compared to placebo 2
• Corticosteroids lead to significant improvement in FEV1 within the first 72 hours of treatment (mean difference of 140 mL compared to placebo) 2

Clinical Outcomes

• Systemic corticosteroids reduce the risk of early relapse following an acute exacerbation 1, 2
• They shorten hospital length of stay by approximately 1.22 days compared to placebo treatment 2
• The rate of relapse by one month is significantly lower with systemic corticosteroid treatment (hazard ratio 0.78) 2
• The number needed to treat with systemic corticosteroids to avoid one treatment failure is 9 patients 2

Dosing and Administration

• A dose of 40 mg prednisone per day for 5 days is the recommended regimen for acute COPD exacerbations 1
• Oral administration is equally effective as intravenous administration, making oral therapy the preferred route when possible 1, 2
• Using standardized order sets with 5-day steroid courses has been shown to reduce both cumulative steroid dose and hospital length of stay without increasing readmission rates 3

Important Considerations and Caveats

• Corticosteroids may be more effective in exacerbations associated with increased sputum or blood eosinophils 1
• Short-term use of systemic corticosteroids carries risks including hyperglycemia, weight gain, and insomnia 1, 2
• The risk of adverse effects increases with corticosteroid treatment (odds ratio 2.33), with one extra adverse effect occurring for every six people treated 2
• Hyperglycemia is a particularly common adverse effect (odds ratio 2.79) 2
• Systemic corticosteroids are only recommended for the acute treatment period and should not be continued long-term solely to prevent future exacerbations beyond the first 30 days 1

Clinical Application

• For acute exacerbations, treatment should be initiated promptly to maximize benefits 1
• The recommended duration of therapy should not exceed 5-7 days 1
• Benefits of corticosteroids are primarily seen in the first 72 hours, with limited evidence for maintained benefit beyond this period 4
• In patients with both COPD exacerbation and pneumonia, the benefits of systemic corticosteroids may be less clear, with some studies showing no difference in length of stay or treatment failure rates 5

The evidence strongly supports the use of systemic corticosteroids in acute exacerbations of COPD as they provide significant clinical benefits in terms of improved lung function, reduced treatment failure, and shortened recovery time, despite the increased risk of adverse effects that must be monitored.