Prednisone for COPD Exacerbation

For COPD exacerbations, prescribe prednisone 40 mg daily for 5 days without tapering. 1, 2

Recommended Dosing Regimen

The standard dose is 40 mg prednisone daily (or equivalent) for exactly 5 days 1, 2
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines specifically recommend this 40 mg daily dose for 5 days, representing high-quality evidence 1, 2
Alternative acceptable dosing is 30-40 mg daily, though 40 mg is preferred 2, 3

Do not extend treatment beyond 5-7 days - longer courses provide no additional benefit while increasing adverse effects 1, 2
A landmark randomized trial (REDUCE) demonstrated that 5-day treatment was non-inferior to 14-day treatment for preventing reexacerbation within 6 months, while significantly reducing total glucocorticoid exposure (379 mg vs 793 mg cumulative dose) 4
Durations of 5-7 days are sufficient, with most clinical benefit occurring in the first 3-5 days 2

For 5-7 day courses, do not taper the dose - tapering is unnecessary and may lead to underdosing during the critical recovery period 1
Discontinue abruptly after completing the 5-day course 1

Oral administration is strongly preferred over intravenous 2, 3, 5
Oral prednisolone is equally effective to IV administration for treatment failure, hospital readmissions, and length of stay 3, 5
A large observational study of 80,000 non-ICU patients showed IV corticosteroids were associated with longer hospital stays and higher costs without clear benefit 2, 3
IV administration carries higher risk of adverse effects, particularly hyperglycemia (70% vs 20% in one study) 3

Reserve IV hydrocortisone 100 mg for patients unable to take oral medications due to vomiting, inability to swallow, or impaired GI function 3
Transition to oral as soon as the patient can tolerate oral intake 3

Blood eosinophil count ≥2% predicts better response to corticosteroids - treatment failure rates of only 11% versus 66% with placebo 2
However, treat all COPD exacerbations with corticosteroids regardless of eosinophil levels, as guidelines recommend universal treatment 2
Patients with eosinophil count <2% may have less benefit but should still receive treatment 2, 3

Corticosteroids shorten recovery time, improve lung function (FEV1) and oxygenation 1, 2
They reduce early relapse risk, treatment failure, and length of hospitalization 1, 2
They prevent hospitalization for subsequent exacerbations in the first 30 days following the initial exacerbation 2, 3

Don't prescribe longer than 5-7 days - this increases side effects (hyperglycemia, weight gain, insomnia) without improving outcomes 1, 2, 3
Don't use IV corticosteroids as default for hospitalized patients - oral is equally effective with fewer adverse effects 3, 5
Don't delay initiation - start corticosteroids early in the exacerbation for optimal effect 1
Don't continue corticosteroids long-term after the acute exacerbation for preventing future exacerbations beyond 30 days - no evidence supports this and risks outweigh benefits 2, 3
Real-world data shows only 2.1% of patients receive both appropriate dose and duration, with most receiving excessive doses and durations 6

If prednisone unavailable, use methylprednisolone or prednisolone at equivalent doses 1
For IV administration when necessary: hydrocortisone 100 mg is equivalent to prednisolone 30 mg daily 3
Oral administration is strongly preferred when patient can tolerate it 1, 3

Transition to maintenance therapy with inhaled corticosteroid/long-acting β-agonist combination or inhaled long-acting anticholinergic monotherapy to prevent future exacerbations 2, 3
Do not continue systemic corticosteroids for maintenance 2, 3