What is the recommended steroid treatment for an elderly patient with a history of Chronic Obstructive Pulmonary Disease (COPD) experiencing an exacerbation, according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 guidelines?

Steroid Treatment for COPD Exacerbations: GOLD 2025 Recommendations

For elderly patients with COPD exacerbations, administer prednisone 30-40 mg orally once daily for 5 days, combined with short-acting bronchodilators. 1, 2, 3

Dosing Protocol

The standard regimen is prednisone 30-40 mg orally daily for exactly 5 days—no longer, no shorter. 1, 2, 3

• A 5-day course is as effective as 10-14 day courses for improving lung function and symptoms while minimizing adverse effects 1, 2, 3, 4
• Do not extend treatment beyond 5-7 days, as this increases adverse effects without providing additional clinical benefit 1, 3
• The total cumulative dose should not exceed 200 mg prednisone equivalents for the exacerbation course 3

Route of Administration

Oral prednisone is strongly preferred over intravenous corticosteroids. 1, 3

• Oral administration is equally effective for clinical outcomes and reduces the risk of adverse effects compared to IV administration 1, 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 1
• Use IV hydrocortisone 100 mg only if the patient cannot take oral medications 6, 1, 3

Treatment Algorithm by Severity

Mild/Ambulatory Exacerbations

• Prednisone 40 mg orally daily for 5 days 2, 3
• Short-acting bronchodilators via MDI or nebulizer 2, 3
• Antibiotics only if 2 or more criteria present: increased breathlessness, increased sputum volume, or purulent sputum 6, 3

Moderate Exacerbations

• Prednisone 40 mg orally daily for 5 days 2, 3
• Nebulized short-acting bronchodilators 2, 3
• Antibiotics if indicated by purulent sputum criteria 3

Severe/Hospitalized Exacerbations

• Prednisone 40 mg orally daily for 5 days (or IV hydrocortisone 100 mg if unable to take oral) 1, 2, 3
• Nebulized short-acting β2-agonists 2, 3
• Antibiotics for increased sputum purulence plus either increased dyspnea or increased sputum volume 3

Clinical Benefits

Systemic corticosteroids provide substantial benefits in COPD exacerbations. 1, 5

• Reduce treatment failure by over 50% compared to placebo (OR 0.48) 5
• Prevent hospitalization for subsequent exacerbations within the first 30 days (HR 0.78) 1, 2
• Improve FEV1 by mean 140 mL within 72 hours 5
• Shorten hospital length of stay by 1.22 days 5
• Accelerate recovery of oxygenation and reduce dyspnea 7

Role of Blood Eosinophils

Blood eosinophil count ≥2% predicts better response to corticosteroids, but treatment should NOT be withheld based on eosinophil levels. 1, 3

• Patients with eosinophils ≥2% show treatment failure rates of only 11% versus 66% with placebo 1
• Current guidelines recommend treating all COPD exacerbations requiring emergent care regardless of eosinophil levels 1, 3
• Consider checking eosinophil count to predict response, but do not delay treatment 1

Adverse Effects to Monitor

Short-term corticosteroid use carries predictable risks that require monitoring. 1, 2, 5

• Hyperglycemia (OR 2.79)—monitor blood glucose closely, especially in diabetics 1, 2, 5
• Weight gain and fluid retention 1, 2
• Insomnia 1, 2
• Worsening hypertension, particularly with IV administration 1
• Overall, one extra adverse effect occurs for every 6 people treated 5

Critical Limitations and Pitfalls

Do not use systemic corticosteroids beyond the acute exacerbation period. 1, 3

• Never extend corticosteroid treatment beyond 5-7 days for a single exacerbation 1, 3
• Systemic corticosteroids should NOT be given for the sole purpose of preventing exacerbations beyond the first 30 days following the initial event (Grade 1A recommendation) 1, 3
• No evidence supports long-term corticosteroid use to reduce COPD exacerbations, and risks (infection, osteoporosis, adrenal suppression) far outweigh any benefits 1, 3
• Do not use methylxanthines (theophylline) as they have increased side effect profiles without added benefit 1, 3

Post-Treatment Maintenance

After completing the 5-day prednisone course, optimize inhaled maintenance therapy to prevent future exacerbations. 1, 2

• Initiate or optimize inhaled corticosteroid/long-acting beta-agonist combination therapy 1, 2
• Consider long-acting anticholinergic monotherapy as an alternative 1
• This maintenance therapy prevents future exacerbations and maintains the improved lung function achieved during acute treatment 2

Special Considerations for Elderly Patients

The same 5-day prednisone regimen applies to elderly patients, but heightened monitoring is essential. 1, 2

• Elderly patients are at higher risk for hyperglycemia—check blood glucose more frequently 2
• Consider calcium, vitamin D, and bisphosphonates if recurrent exacerbations require repeated corticosteroid courses 2
• Ensure adequate support at home if discharged from emergency department 6
• Verify patient or caregiver understands medication regimen and inhaler technique 6