From the Guidelines
Systemic corticosteroids are recommended for COPD exacerbations, even in the setting of viral pneumonia, due to their ability to reduce inflammation, decrease mucus production, and improve airflow, as supported by the European Respiratory Society/American Thoracic Society guideline 1. The standard regimen is oral prednisone 40mg daily for 5 days, though alternative options include methylprednisolone 32mg daily or dexamethasone 6mg daily for the same duration. These medications lead to faster symptom resolution and reduced hospital stays, as noted in the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report 1. While there have been concerns about using steroids with viral infections, particularly with COVID-19, the benefits typically outweigh the risks in COPD exacerbations. Key considerations include:
- Patients should also receive appropriate bronchodilators (such as albuterol and ipratropium) and antibiotics if bacterial infection is suspected, as outlined in the global strategy report 1.
- Oxygen therapy should be provided to maintain saturation between 88-92%.
- Monitor for potential side effects of steroids including hyperglycemia, mood changes, and insomnia.
- In severe cases requiring hospitalization, initial intravenous steroids may be used before transitioning to oral therapy, although the evidence suggests that oral corticosteroids may have a similar efficacy to intravenous corticosteroids with potentially fewer adverse effects 1. The decision to use steroids should be individualized based on the severity of the exacerbation and the patient's overall condition.
From the Research
Use of Steroids for Treatment of COPD Exacerbation in the Setting of a Viral Pneumonia
- The use of steroids for the treatment of COPD exacerbation in the setting of a viral pneumonia is a topic of interest, with several studies investigating the effectiveness and risks associated with this treatment approach 2, 3, 4.
- A multicenter, retrospective cohort study found that systemic steroid therapy may not improve the time to clinical stability in patients with pneumonic COPD exacerbation of mild to moderate severity 2.
- A meta-analysis of randomized controlled trials found that inhaled corticosteroids (ICS) increase the risk of pneumonia in COPD patients, with a significantly increased risk of severe pneumonia 3.
- The risk of pneumonia associated with ICS use in COPD patients is prominent for fluticasone-containing ICSs but not for budesonide-containing ICSs 3.
- The use of inhaled corticosteroids in patients with COPD and chronic bronchial infection may even increase the bacterial load in the airways and increase the risk of pneumonia 5.
Key Findings
- Systemic steroid therapy─ possibly not beneficial for mild to moderate pneumonic COPD exacerbation 2.
- Inhaled corticosteroids─ increase the risk of pneumonia in COPD patients, especially with fluticasone-containing ICSs 3.
- Antibiotic prophylthesis may be beneficial in preventing COPD exacerbations, particularly in patients with severe or very severe COPD 5, 6.
Considerations
- The decision to use steroids for the treatment of COPD exacerbation in the setting of a viral pneumonia should be made on a case-by-case basis, taking into account the potential risks and benefits 5, 6.
- Further research is needed to evaluate the effectiveness of systemic steroid therapy in more severe patients and to understand the mechanisms of increased pneumonia risk with inhaled corticosteroids 2, 4.