What is the role of steroids in treating bronchitis, specifically chronic bronchitis or chronic obstructive pulmonary disease (COPD) exacerbation?

Role of Steroids in Treating Chronic Bronchitis and COPD Exacerbations

For acute exacerbations of COPD or chronic bronchitis, a short course (≤14 days) of oral corticosteroids is recommended as it improves lung function, shortens recovery time, and may reduce the risk of hospitalization. 1

Acute Exacerbations of Chronic Bronchitis/COPD

• Systemic corticosteroids (oral or IV) are beneficial in managing acute exacerbations of COPD, with a recommended dose of 30-40 mg prednisone daily for 5-14 days 1
• Corticosteroids during exacerbations improve lung function, reduce recovery time, and may reduce the risk of early relapse and treatment failure 1
• The European Respiratory Society/American Thoracic Society (ERS/ATS) guidelines suggest a short course (≤14 days) of oral corticosteroids for ambulatory patients with COPD exacerbations (conditional recommendation) 1
• Several studies suggest that even shorter durations of systemic corticosteroid treatment (3-7 days) may be as effective as longer courses in hospitalized patients 1

Benefits of Steroids in Exacerbations

• Systemic corticosteroids improve lung function (FEV1) within the first 72 hours of an exacerbation 2
• Corticosteroids reduce treatment failure rates compared to placebo in acute exacerbations 1
• The American College of Chest Physicians recommends systemic corticosteroids for acute exacerbations to prevent hospitalization for subsequent exacerbations in the first 30 days following the initial exacerbation 1

Personalized Approach Based on Blood Eosinophils

• Patients with elevated blood eosinophil counts (≥2%) show greater improvement in health-related quality of life and faster recovery with oral corticosteroids compared to placebo 1
• Patients with sputum eosinophilia are more likely to respond favorably to steroid therapy than those without 3
• In patients with blood eosinophils <2%, the benefits of steroids are less clear, with some evidence suggesting placebo might be equally or more effective 1

Stable Chronic Bronchitis/COPD

• There is no proven benefit for oral corticosteroids in stable chronic bronchitis, and they are not recommended for long-term maintenance therapy 1, 4
• Inhaled corticosteroids have not shown consistent benefits in short-term studies (up to 3 months) for patients with chronic bronchitis without severe airflow limitation 5, 6
• For patients with severe or very severe airflow obstruction (FEV1 <50% predicted) or frequent exacerbations, inhaled corticosteroids may be beneficial in reducing exacerbation rates 4, 6
• Combined therapy with a long-acting β-agonist and an inhaled corticosteroid has shown benefits in reducing exacerbation rates and cough in long-term trials 4

Treatment Algorithm for Chronic Bronchitis/COPD

For Acute Exacerbations:

1. Start with short-acting bronchodilators (β-agonists or anticholinergics) 1, 4
2. Add systemic corticosteroids for 5-14 days (30-40 mg prednisone daily) 1, 4
3. Consider antibiotics if bacterial infection is suspected 4

For Stable Disease:

1. Use short-acting bronchodilators as first-line therapy 1, 4
2. For patients with FEV1 <50% predicted or frequent exacerbations, add inhaled corticosteroids 4
3. Consider combination therapy with long-acting β-agonist plus inhaled corticosteroid for persistent symptoms 4
4. Avoid long-term systemic corticosteroids due to lack of benefit and significant side effects 1, 4

Important Considerations and Cautions

• Systemic corticosteroids are associated with adverse effects including hyperglycemia, weight gain, insomnia, and increased risk of infection 1, 7
• The benefits of short-term corticosteroids in acute exacerbations outweigh the risks of adverse effects 1
• Long-term use of systemic corticosteroids is not recommended due to significant side effects including osteoporosis, hyperglycemia, and immunosuppression 1, 4, 7
• Short-term inhaled corticosteroids (4 weeks) have not been shown to significantly attenuate airway inflammation in patients with chronic bronchitis 5