What are the indications and guidelines for steroid use in respiratory cases, such as asthma exacerbations, Chronic Obstructive Pulmonary Disease (COPD) exacerbations, and pneumonia?

Steroid Indications and Guidelines in Respiratory Cases

For respiratory conditions including asthma, COPD, and pneumonia, systemic corticosteroids are strongly recommended for acute exacerbations, while inhaled corticosteroids have specific maintenance indications based on disease severity and exacerbation history.

Systemic Corticosteroids for Acute Exacerbations

COPD Exacerbations

• Systemic corticosteroids (oral or IV) are recommended for acute COPD exacerbations to prevent hospitalization for subsequent exacerbations within 30 days 1
• The recommended dosage is 40 mg prednisone daily for 5 days 1
• Oral administration is equally effective as intravenous administration and is preferred when possible 1, 2
• Short-term systemic corticosteroids (5-7 days) improve lung function, oxygenation, shorten recovery time, and decrease length of hospitalization 1, 2
• Benefits include reduced risk of early relapse and treatment failure 1

Asthma Exacerbations

• Systemic corticosteroids are the cornerstone of treatment for acute asthma exacerbations 1
• For pediatric patients with uncontrolled asthma despite inhaled corticosteroids and long-acting bronchodilators, the National Heart, Lung, and Blood Institute recommends 1-2 mg/kg/day of methylprednisolone (or equivalent) 3
• "Burst therapy" should be continued until peak expiratory flow reaches 80% of personal best or symptoms resolve (typically 3-10 days) 3
• No evidence supports tapering the dose after improvement 3

Pneumonia Considerations

• Systemic corticosteroids may not provide clinical benefit to patients with both COPD exacerbation and pneumonia 4
• In severe community-acquired pneumonia with markedly increased inflammation markers, corticosteroids may be considered 5

Inhaled Corticosteroids for Maintenance Therapy

COPD Maintenance Therapy

• For stable moderate, severe, and very severe COPD, maintenance combination inhaled corticosteroid/long-acting β-agonist therapy is recommended over long-acting β-agonist monotherapy to prevent acute exacerbations (Grade 1C) 2
• Maintenance combination inhaled corticosteroid/long-acting β-agonist therapy is recommended over inhaled corticosteroid monotherapy (Grade 1B) 2
• Inhaled corticosteroid monotherapy is not supported for COPD 2
• Primary indications for inhaled corticosteroids in COPD:
  • Frequent exacerbations (≥2 per year) despite optimal bronchodilator therapy 2
  • FEV1 <50-60% predicted 2
  • Asthma-COPD overlap syndrome 2

Asthma Maintenance Therapy

• Inhaled corticosteroids are the cornerstone of maintenance therapy for persistent asthma 1
• They are more effective than oral corticosteroids for long-term control with fewer systemic side effects 6

Important Clinical Considerations

Biomarkers for Steroid Response

• 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
• COPD patients who respond to corticosteroids often have eosinophilic inflammation and attributes of an asthma phenotype 6

Side Effects and Risks

• Long-term use of systemic corticosteroids should be avoided due to risks of hyperglycemia, weight gain, infection, osteoporosis, and adrenal suppression 1
• Inhaled corticosteroids increase the risk of pneumonia in COPD patients 2, 7, 8
• Other side effects of inhaled corticosteroids include oropharyngeal candidiasis and hoarseness 7

Duration of Therapy

• Duration of systemic corticosteroid therapy for acute exacerbations should not exceed 5-7 days 1
• Systemic corticosteroids help prevent hospitalization for subsequent acute exacerbations only in the first 30 days following the initial exacerbation 1, 2
• For treatments shorter than 10-14 days, corticosteroids can be abruptly stopped, but patients should be monitored for symptoms of adrenal insufficiency 5

Combination Therapy Approaches

COPD Triple Therapy

• For stable COPD, maintenance combination of inhaled long-acting anticholinergic/corticosteroid/long-acting β-agonist therapy or inhaled long-acting anticholinergic monotherapy are both effective to prevent acute exacerbations (Grade 2C) 2
• Triple therapy should be considered for patients with more severe COPD (GOLD category D) 2

Additional Therapies

• For moderate to severe COPD with history of exacerbations despite optimal maintenance inhaler therapy, long-term macrolide therapy may be considered (Grade 2A) 2
• Roflumilast is recommended in patients with severe COPD with characteristics of chronic bronchitis and a history of exacerbations in most countries 2