What is the role of corticosteroids, such as prednisone (corticosteroid) and fluticasone (corticosteroid), in the management of Chronic Obstructive Pulmonary Disease (COPD)?

Role of Corticosteroids in COPD Management

Corticosteroids play a crucial but differentiated role in COPD management, with systemic corticosteroids being highly effective for acute exacerbations while inhaled corticosteroids have a more selective role in stable COPD based on specific patient characteristics. 1

Systemic Corticosteroids for Acute COPD Exacerbations

• Systemic corticosteroids (oral or intravenous) are strongly recommended for acute COPD exacerbations as they improve lung function, shorten recovery time, and reduce risk of treatment failure 1
• For ambulatory patients experiencing COPD exacerbations, a short course (≤14 days) of oral corticosteroids is recommended 2
• The optimal regimen is 40mg prednisone daily for 5 days, with oral administration being equally effective as intravenous administration 1
• Systemic corticosteroids improve oxygenation during acute exacerbations, contributing to faster clinical improvement and reduced risk of early relapse 1
• Treatment with oral prednisone for acute exacerbations accelerates recovery of arterial PO₂, improves FEV₁ and peak expiratory flow, and reduces treatment failure rates 3

Clinical Benefits in Exacerbations

• Systemic corticosteroids increase the rate of lung function improvement over the first 72 hours of an exacerbation 4
• Patients with blood eosinophil counts ≥2% may show greater response to corticosteroids during exacerbations 2
• Treatment should be initiated promptly to maximize benefits and limited to 5-7 days to minimize adverse effects 1

Inhaled Corticosteroids (ICS) in Stable COPD

• The role of inhaled corticosteroids in stable COPD is more limited and controversial compared to their established role in asthma 5
• Short-term studies show no or marginal beneficial effects on symptoms, lung function, and hyperresponsiveness in stable COPD 2
• Only about 10% of patients with stable COPD will achieve a significant improvement in FEV₁ with corticosteroid therapy 2
• ICS can reduce lymphocytic inflammation in COPD airways, with potentially more pronounced effects in patients with predominant lymphocytic airway inflammation 2
• Treatment with inhaled budesonide for 6 months has been shown to reduce neutrophils and IL-8 concentration in bronchoalveolar lavage, indicating an anti-inflammatory effect, though without significant improvement in lung function 6

Appropriate Use of ICS in Stable COPD

• Long-term oral corticosteroids should be administered only when there is a clear functional benefit (increase in postbronchodilator FEV₁ of 10% predicted and an absolute increase of at least 200 mL) 2
• Lower doses of ICS may provide benefits while minimizing risks, especially pneumonia 7
• ICS should not be continued long-term solely to prevent future exacerbations beyond the first 30 days after an acute exacerbation 1

Adverse Effects and Cautions

• Well-known side-effects of systemic corticosteroids include obesity, muscle weakness, hypertension, psychiatric disorders, diabetes mellitus, osteoporosis, skin thinning, and bruising 2
• Short-term use of systemic corticosteroids carries risks including hyperglycemia, weight gain, and insomnia 1
• Inhaled corticosteroids have fewer systemic side-effects than oral corticosteroids, but high doses (>1,000 μg/day) may increase risks of osteoporosis and skin thinning 2
• Common side effects of inhaled corticosteroids include oral candidiasis and hoarseness, which can be minimized by using large-volume spacers and rinsing the mouth after use 2
• The use of ICS in COPD has been associated with an increased risk of pneumonia, though this risk appears to be dose-dependent 7

Clinical Decision Algorithm

1. For acute exacerbations:

   • Prescribe oral prednisone 40mg daily for 5 days 1
   • Consider blood eosinophil count to predict response (better response if ≥2%) 2
   • Monitor for hyperglycemia and other short-term adverse effects 1

2. For stable COPD:

   • Consider ICS only in combination with long-acting bronchodilators 2
   • Conduct a trial of corticosteroids (0.4-0.6 mg/kg for 2-4 weeks) to test reversibility 2
   • Continue ICS only if there is a clear functional benefit (≥10% improvement in FEV₁ and ≥200mL absolute increase) 2
   • Use the lowest effective dose to minimize adverse effects 7
   • Monitor for local side effects (candidiasis, hoarseness) and instruct patients on proper inhaler technique and mouth rinsing 2