From the Guidelines
Oral corticosteroids are recommended over intravenous corticosteroids for treating acute exacerbations of COPD, due to equivalent efficacy, lower cost, and greater convenience, as well as a potentially lower risk of adverse events. The evidence from the European Respiratory Society/American Thoracic Society guideline 1 suggests that there are no significant differences in treatment failure, mortality, hospital readmissions, or length of hospital stay between intravenous and oral corticosteroids. The guideline also notes that one trial-desktop demonstrated an increased risk of mild adverse effects in the intravenous corticosteroids group, which were easily treated with appropriate medications 1.
The recommended dose of oral prednisone is 40-60mg daily for 5-7 days, as this has been shown to be effective in improving lung function, reducing hospital length of stay, and preventing treatment failure 1. For patients unable to take oral medications due to vomiting or altered mental status, methylprednisolone 60-125mg IV every 6 hours can be used until oral therapy becomes feasible.
Some key points to consider when treating acute exacerbations of COPD with corticosteroids include:
- The equivalence of oral and intravenous routes in achieving systemic anti-inflammatory effects needed to reduce airway inflammation and bronchospasm 1
- The preference for shorter courses (5-7 days) over longer courses, as they provide similar benefits with fewer side effects such as hyperglycemia, mood disturbances, and increased infection risk 1
- The importance of continuing inhaled corticosteroids alongside systemic therapy during the acute exacerbation, for patients already using them 1
- The consideration of noninvasive mechanical ventilation for patients with acute or acute-on-chronic respiratory failure, as recommended by the European Respiratory Society/American Thoracic Society guideline 1
From the Research
Comparison of IV and PO Steroid in Acute COPD
- The study 2 found that treatment with oral or parenteral corticosteroids increases the rate of lung function improvement over the first 72 hours of an exacerbation of chronic obstructive pulmonary disease.
- However, the same study 2 noted that there is no evidence that this benefit is maintained after 72 hours, or that other outcomes are improved.
- A comparison of IV methylprednisolone followed by oral methylprednisolone with IV hydrocortisone followed by oral prednisolone in patients with AECOPD found that IV methylprednisolone followed by oral methylprednisolone produced greater improvement in FEV(1) and PEF at 2 weeks 3.
- The review 4 noted that steroids are supported by strong evidence of their efficacy in severe AECOPD patients requiring hospitalization.
- Another review 5 stated that strong evidence exists for the benefit of corticosteroids for exacerbations, but there remains considerable uncertainty in the best drug selection, dose, route, and duration of treatment.
- A comprehensive review 6 discussed the management of COPD exacerbations, including pharmacologic and non-pharmacologic strategies, but did not specifically compare IV and PO steroid administration.
Key Findings
- Corticosteroids, whether administered orally or parenterally, improve lung function in the short term 2.
- The choice between IV and PO steroid administration may affect outcomes, with one study 3 suggesting that IV methylprednisolone followed by oral methylprednisolone may be more effective than IV hydrocortisone followed by oral prednisolone.
- Further research is needed to determine the optimal route and duration of corticosteroid treatment for COPD exacerbations 5.