Are steroid inhalers effective for acute exacerbations of respiratory conditions like asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Steroid Inhalers for Acute Exacerbations of Respiratory Conditions

Systemic corticosteroids, not inhaled corticosteroids, are recommended for treating acute exacerbations of COPD, as they improve lung function, oxygenation, and shorten recovery time and hospitalization duration. 1

Acute Exacerbation Management

Pharmacological Treatment for Acute COPD Exacerbations

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators recommended for acute treatment of exacerbations 1
• Systemic glucocorticoids (oral or intravenous) are recommended for COPD exacerbations as they:
  • Shorten recovery time and improve FEV1
  • Improve oxygenation
  • Reduce risk of early relapse and treatment failure
  • Decrease length of hospitalization 1
• The recommended dosage is 40 mg prednisone per day for 5 days 1
• Oral prednisolone is equally effective as intravenous administration 1

Inhaled Corticosteroids in Acute Settings

• Current guidelines do not recommend inhaled corticosteroids as primary treatment for acute exacerbations 1
• Systemic corticosteroids are preferred over inhaled corticosteroids during acute exacerbations due to their more rapid and comprehensive anti-inflammatory effects 2
• While some studies have explored using nebulized corticosteroids in acute settings, this practice requires further confirmation and cannot be currently recommended 3

Important Clinical Considerations

Patient-Specific Factors

• Patients with exacerbations associated with increased sputum or blood eosinophils may be more responsive to systemic steroids 1
• Glucocorticoids may be less efficacious in treating exacerbations in patients with lower blood eosinophil levels 1
• Some evidence suggests that COPD patients who respond to corticosteroids have eosinophilic inflammation and other attributes of an asthma phenotype 4

Duration of Treatment

• Duration of systemic corticosteroid therapy for acute exacerbations should not exceed 5-7 days 1
• For patients with an acute exacerbation of COPD in outpatient or inpatient settings, systemic corticosteroids help prevent hospitalization for subsequent acute exacerbations in the first 30 days following the initial exacerbation 1

Common Pitfalls and Caveats

• Intravenous methylxanthines are not recommended due to increased side effect profiles 1
• Long-term use of systemic corticosteroids should be avoided due to risks of hyperglycemia, weight gain, infection, osteoporosis, and adrenal suppression 1
• An acute exacerbation while on oral corticosteroids does not necessarily indicate the need for long-term inhaled corticosteroids 1
• The use of systemic corticosteroids to treat an acute exacerbation has not been shown to reduce acute exacerbations beyond the 30-day window 1

Role of Inhaled Corticosteroids

While inhaled corticosteroids are not the primary treatment for acute exacerbations, they play an important role in preventing future exacerbations:

• For stable moderate to very severe COPD, maintenance combination inhaled corticosteroid/long-acting β-agonist therapy is recommended to prevent acute exacerbations 1
• Inhaled corticosteroids are the mainstay of anti-inflammatory treatment for long-term management of asthma and, to a lesser extent, COPD 5
• Nebulized corticosteroids may be considered as an alternative to inhalers for delivering ICSs in patients who are unwilling or unable to use inhalers, but not specifically for acute exacerbations 3