What is the recommended treatment for an older adult patient with a history of chronic obstructive pulmonary disease (COPD) and smoking, presenting with a COPD exacerbation?

Systemic Corticosteroid Therapy for COPD Exacerbations

For acute COPD exacerbations, administer prednisone 40 mg orally once daily for exactly 5 days—this is the evidence-based standard that reduces treatment failure by over 50%, shortens recovery time, and minimizes cumulative steroid exposure compared to longer courses. 1

Corticosteroid Dosing and Duration

The 5-day regimen is equally effective as 10-14 day courses but reduces cumulative steroid exposure by over 50%. 1, 2 Multiple high-quality guidelines converge on this recommendation:

• Dose: 30-40 mg prednisone (or prednisolone) orally once daily 3, 1, 4
• Duration: Exactly 5 days—do not extend beyond 5-7 days unless there is a separate indication 3, 1
• Route: Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 5

The evidence supporting shorter courses is compelling. A large Cochrane review of 1,620 patients demonstrated that systemic corticosteroids reduce treatment failure with an odds ratio of 0.48 (95% CI 0.35-0.67), meaning you need to treat only 9 patients to prevent one treatment failure. 4 Importantly, a well-powered non-inferiority study found no difference in time to next exacerbation when comparing 5 days versus 14 days of treatment. 2

Clinical Benefits and Mechanism

Systemic corticosteroids provide multiple benefits in COPD exacerbations:

• Improve lung function (FEV1) within the first 72 hours by approximately 140 mL 4
• Improve oxygenation and reduce hypoxemia 3, 1
• Shorten recovery time and hospital length of stay by approximately 1.2 days 3, 4
• Reduce relapse rates within the first 30 days (hazard ratio 0.78; 95% CI 0.63-0.97) 4
• Prevent recurrent exacerbations within 30 days but provide no benefit beyond this window 1

Critical Pitfalls to Avoid

Do not taper the corticosteroid dose. 6 Tapering is unnecessary for short courses and only increases cumulative steroid exposure without additional benefit. The risk of hypothalamic-pituitary-adrenal axis suppression is negligible with 5-day courses, and abruptly stopping does not increase relapse risk. 6

Do not extend treatment beyond 5-7 days for a single exacerbation. 1 Higher doses and longer durations increase adverse effects without improving outcomes. 6, 4

Do not use systemic corticosteroids for long-term exacerbation prevention. 1 The risks far outweigh any benefits in this context.

Adverse Effects and Monitoring

Corticosteroid treatment increases the likelihood of adverse events with an odds ratio of 2.33 (95% CI 1.59-3.43)—one extra adverse effect occurs for every 6 patients treated. 4 The most significant concern is hyperglycemia, with an odds ratio of 2.79 (95% CI 1.86-4.19). 4

Monitor blood glucose in all patients, particularly those with diabetes or pre-diabetes, as hyperglycemia risk increases substantially. 4

Special Considerations

Corticosteroids may be less efficacious in patients with lower blood eosinophil levels, though this should not preclude treatment in acute exacerbations. 1

For outpatient management, the same 5-day oral regimen applies for moderate exacerbations (defined as requiring bronchodilators plus antibiotics and/or corticosteroids). 3, 1 Mild exacerbations treated with bronchodilators alone do not require corticosteroids. 3, 1

For hospitalized patients, oral prednisolone 30-40 mg daily for 5 days remains the standard, with IV administration reserved only for patients unable to take oral medications. 1, 5 A randomized controlled trial of 210 hospitalized patients demonstrated that oral prednisolone was non-inferior to IV administration for treatment failure (56.3% vs 61.7%), length of stay, and all other outcomes. 5

Integration with Other Therapies

Corticosteroids should be combined with:

• Short-acting bronchodilators (beta-agonists with or without anticholinergics) as first-line therapy 3, 1
• Antibiotics for 5-7 days when indicated (increased sputum purulence plus either increased dyspnea or increased sputum volume) 1
• Controlled oxygen targeting SpO2 88-92% in hospitalized patients 1
• Noninvasive ventilation as first-line for acute hypercapnic respiratory failure 3, 1

Initiate or optimize long-acting bronchodilator maintenance therapy before hospital discharge to prevent future exacerbations. 3, 1