Prednisolone Taper for COPD Exacerbation
For COPD exacerbations, give prednisolone 30-40 mg orally once daily for 5 days without any taper. Modern evidence strongly supports short-course therapy without tapering, as longer courses provide no additional benefit and increase adverse effects 1, 2.
Recommended Dosing Regimen
The standard regimen is prednisolone 30 mg orally once daily for 5 days, then stop. 1, 2
- The GOLD guidelines recommend 40 mg prednisone daily for 5 days 1, 2
- The British Thoracic Society and NICE guidelines recommend 30 mg daily for 7-14 days 1
- However, the most recent high-quality evidence from the REDUCE trial demonstrates that 5 days is non-inferior to 14 days 3
Key Evidence Supporting Short-Course Therapy
The REDUCE randomized trial (314 patients) definitively showed that 5-day treatment was non-inferior to 14-day treatment for preventing re-exacerbation within 180 days, while significantly reducing total glucocorticoid exposure (379 mg vs 793 mg cumulative dose) 3. A Cochrane meta-analysis confirmed no difference in treatment failure, relapse rates, or adverse events between short-duration (≤7 days) and longer-duration (>7 days) courses 4.
No Taper Required
Abrupt discontinuation after 5 days is appropriate and does not require tapering. 1, 2, 3
- Short courses of 5-7 days do not suppress the hypothalamic-pituitary-adrenal axis sufficiently to warrant tapering 2
- The REDUCE trial used abrupt cessation after 5 days without adverse consequences 3
- Extending treatment beyond 5-7 days increases adverse effects without clinical benefit 2, 4
Route of Administration
Oral prednisolone is preferred over intravenous administration. 1, 2, 5
- Oral and IV routes are equally effective for treatment failure, mortality, hospital readmissions, and length of stay 1, 5
- IV corticosteroids are associated with longer hospital stays, higher costs, and potentially more adverse effects 2
- Reserve IV hydrocortisone 100 mg for patients unable to take oral medications due to vomiting or impaired GI function 2, 6
Patient Selection Considerations
Blood eosinophil count may help predict response to corticosteroids, though treatment should not be withheld based on this alone. 2, 7
- Patients with blood eosinophil count ≥2% show better response to oral corticosteroids 2, 7
- The STARR2 trial showed that eosinophil-directed therapy (giving prednisolone only if eosinophils ≥2%) was non-inferior to standard care 7
- However, in clinical practice, most clinicians treat all moderate-to-severe exacerbations with corticosteroids regardless of eosinophil count 1
Common Pitfalls to Avoid
Do not extend corticosteroid treatment beyond 7 days. Longer courses increase risks of hyperglycemia, infection, and other adverse effects without improving outcomes 2, 4.
Do not use tapering schedules for short courses. The evidence supports abrupt cessation after 5 days 3.
Do not default to IV corticosteroids for hospitalized patients. Oral administration is equally effective and has fewer adverse effects 1, 2, 5.
Do not continue systemic corticosteroids long-term after the acute exacerbation. There is no evidence supporting this practice, and risks outweigh benefits 2, 6. Instead, optimize maintenance inhaled therapy with ICS/LABA combinations or LAMA 6.