What is the recommended management for a patient with a pre-existing condition, such as asthma or Chronic Obstructive Pulmonary Disease (COPD), who is on oral steroid (PO steroids) treatment and develops a cold?

Management of Patients on Oral Steroids Who Develop a Cold

Continue the oral steroids as prescribed for the underlying condition (asthma or COPD) and do not discontinue them due to a simple viral upper respiratory infection. 1, 2

Key Management Principles

Continue Baseline Steroid Therapy

• Patients on maintenance oral corticosteroids should continue their prescribed regimen without interruption when they develop a cold. 3, 2
• Abrupt discontinuation of chronic steroid therapy poses significant risks including adrenal crisis, which far outweighs any theoretical concerns about viral infection susceptibility. 4
• The concern about steroids affecting immune response to viral infections has been raised but should not lead to unsolicited medication changes that could trigger severe exacerbations. 4

Assess for Exacerbation vs. Simple Cold

The critical decision point is determining whether this is merely an upper respiratory infection or an actual exacerbation of the underlying lung disease:

For COPD patients, add short-course systemic steroids (prednisolone 30-40 mg daily for 5 days) if the patient develops:

• Increased breathlessness beyond baseline 1
• Increased sputum volume 1, 3
• Development of purulent sputum 1, 3
• Inability to complete sentences, respiratory rate >25/min, or heart rate >110/min 3

For asthma patients, add or increase oral steroids (prednisolone 30-40 mg daily) if:

• Peak expiratory flow drops below 60% of patient's best 2
• Day-by-day worsening of symptoms 2
• Sleep disturbance until midday 2
• Diminishing response to inhaled bronchodilators 2
• Emergency use of nebulized bronchodilators 2

Treatment Duration for Acute Exacerbations

• Limit any additional corticosteroid therapy for acute exacerbations to 5-7 days maximum, as extending beyond this provides no additional benefit while increasing adverse effects. 1
• Short courses (up to 2 weeks) do not require tapering and can be stopped abruptly from full dosage. 2
• For asthma exacerbations, treatment should continue until lung function returns to previous best, which may take 7-21 days in some cases. 2

Concurrent Bronchodilator Therapy

• Increase short-acting β2-agonists (salbutamol 2.5-5 mg nebulized or 200-400 µg via inhaler) every 4-6 hours during symptomatic periods. 3
• Add ipratropium bromide 500 µg if response to β-agonist alone is inadequate. 3
• The combination produces additive bronchodilator effects at submaximal doses. 3

Antibiotic Consideration

• Add antibiotics only if 2 or more of the following are present: increased breathlessness, increased sputum volume, or purulent sputum. 3
• Patients with purulent sputum particularly benefit from antibiotic therapy targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 3
• First-line options include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid for 7-14 days. 3

Critical Pitfalls to Avoid

• Never discontinue chronic oral steroids abruptly due to a viral infection - the risk of adrenal insufficiency and disease exacerbation far exceeds any theoretical viral infection concerns. 4
• Do not use systemic corticosteroids for longer than 14 days for a single exacerbation - no evidence supports extended courses and risks outweigh benefits beyond 30 days. 1
• Avoid defaulting to IV steroids in patients who can take oral medications - oral administration is equally effective with fewer adverse effects and lower costs. 1
• In elderly patients, supervise the first bronchodilator treatment as β-agonists may precipitate angina. 3
• When using ipratropium in patients with glaucoma, use a mouthpiece rather than face mask to minimize ocular exposure. 3

Monitoring and Follow-Up

• Assess clinical improvement in respiratory symptoms (dyspnea, sputum production, wheeze) within 30-60 minutes of initial bronchodilator treatment. 3
• For asthma patients, measure peak expiratory flow 15-30 minutes after starting treatment and monitor according to response. 2
• Continue high-dose steroids until improvement is noted, then return to baseline maintenance dose. 2
• Ensure adequate support at home, especially for elderly patients, and verify understanding of medication regimen and inhaler technique. 1