What is the recommended steroid treatment for patients with Chronic Obstructive Pulmonary Disease (COPD)?

Steroid Treatment for COPD

For patients with COPD, maintenance combination therapy with inhaled corticosteroid/long-acting β-agonist (ICS/LABA) is recommended over monotherapy to prevent exacerbations, while short courses of systemic corticosteroids (5-7 days) are recommended for acute exacerbations. 1

Inhaled Corticosteroid Therapy for Stable COPD

Recommended Approach

• ICS should not be used as monotherapy in COPD patients 1, 2
• Combination ICS/LABA therapy is recommended for patients with moderate to very severe COPD and history of exacerbations 1, 3
• Triple therapy (ICS/LABA/LAMA) may be considered for patients with more severe COPD (GOLD category D) who continue to have exacerbations despite dual therapy 1

Patient Selection for ICS-Containing Therapy

• Best candidates for ICS/LABA therapy are those with:
  • History of multiple or severe exacerbations despite appropriate bronchodilator use 3, 2
  • Blood eosinophil counts >300 cells/μL (stronger response to ICS) 1, 2
  • History of or concomitant asthma 2

Risks and Considerations

• ICS therapy is associated with increased risk of pneumonia, particularly in:
  • Older patients with lower BMI 2
  • Patients with blood eosinophils <100 cells/μL 2
  • Those receiving higher ICS doses 1, 2
• Other potential side effects include oral candidiasis, hoarseness, dysphonia, and bruising 1, 3

Systemic Corticosteroids for COPD Exacerbations

Acute Exacerbation Management

• Systemic corticosteroids are recommended for COPD exacerbations 1
• Recommended dosage: 40mg prednisone daily for 5 days 1, 4
• Oral administration is equally effective as intravenous administration 1
• Short-duration therapy (5-7 days) is as effective as longer courses (10-14 days) with fewer adverse effects 4

Indications for Systemic Corticosteroids in Exacerbations

• Increased dyspnea, sputum volume, and/or sputum purulence 1
• Systemic corticosteroids improve lung function (FEV1), oxygenation, and shorten recovery time and hospitalization duration 1
• Patients with higher blood eosinophil levels may have better response to systemic steroids during exacerbations 1

Cautions with Systemic Corticosteroids

• Long-term use of oral corticosteroids has numerous side effects with no evidence of benefits 1
• Potential adverse effects include hyperglycemia, muscle weakness, and osteoporosis with prolonged use 4
• Should not be continued long-term after an acute exacerbation 1

Treatment Algorithm for COPD Steroid Therapy

1. For stable COPD patients with exacerbation history:

   • First-line: LABA/LAMA combination 1
   • If continued exacerbations or high eosinophil count (>300 cells/μL): Add ICS (triple therapy) 1, 2

2. For acute exacerbations:

   • Short course of systemic corticosteroids (40mg prednisone daily for 5 days) 1, 4
   • Consider antibiotics if increased sputum purulence is present 1
   • Short-acting bronchodilators for symptom relief 1

3. After exacerbation:

   • Return to maintenance therapy; do not continue systemic corticosteroids long-term 1
   • Consider adding or continuing ICS if patient had repeated exacerbations 3, 5

Important Clinical Considerations

• Withdrawing ICS in COPD patients can increase exacerbation risk and shorten time to next exacerbation, particularly in patients with mild COPD 5
• Budesonide/formoterol has shown efficacy in reducing exacerbation rates with potentially lower pneumonia risk compared to fluticasone propionate/salmeterol 3, 6
• The benefit-risk ratio favors ICS/LABA combination therapy with a number needed to treat of 4 patients for 1 year to prevent one moderate to severe exacerbation versus a number needed to harm of 33 patients for pneumonia 3, 7