What is the appropriate systemic corticosteroid treatment (type, dose, route, and duration) for an adult with a moderate‑to‑severe acute COPD exacerbation?

Corticosteroid Treatment for Moderate-to-Severe COPD Exacerbations

For adults with moderate-to-severe acute COPD exacerbations, prescribe oral prednisone 30–40 mg once daily for exactly 5 days, starting immediately at presentation. 1, 2

Type and Route of Corticosteroid

Oral prednisone is the preferred first-line agent over intravenous corticosteroids for all patients who can swallow and tolerate oral medications. 1, 3 Multiple studies demonstrate that oral administration is equally effective to intravenous delivery for treatment failure, hospital readmissions, and length of stay, while oral therapy is associated with fewer adverse effects—particularly hyperglycemia and hypertension. 1, 3

Reserve intravenous hydrocortisone 100 mg for patients who cannot take oral medications due to vomiting, inability to swallow, impaired gastrointestinal absorption, or required NPO status. 1, 3 A large observational study of 80,000 non-ICU patients showed that intravenous corticosteroids were associated with longer hospital stays and higher costs without clear evidence of benefit over oral therapy. 1

Dose and Duration

The optimal regimen is prednisone 30–40 mg orally once daily for exactly 5 days. 1, 2 This short course is as effective as 14-day regimens while reducing cumulative steroid exposure by more than 50%. 1, 4 The 5-day protocol:

• Improves lung function and oxygenation 1, 2, 5
• Shortens recovery time and hospital stay 1, 2
• Reduces treatment failure by over 50% compared to placebo 1, 5
• Lowers the risk of rehospitalization within the first 30 days 1

Do not extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists, as longer courses increase adverse effects (hyperglycemia, weight gain, insomnia, infection, osteoporosis, adrenal suppression) without providing additional clinical benefit. 6, 1, 4, 7, 5

Evidence Quality and Strength

The recommendation for 5-day oral prednisone courses is supported by:

• GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines recommending 30–40 mg prednisone daily for 5 days 1
• European Respiratory Society/American Thoracic Society (ERS/ATS) guidelines endorsing short-course therapy (≤14 days) with emerging evidence supporting 5-day regimens 1
• American College of Chest Physicians suggesting systemic corticosteroids to prevent hospitalization for subsequent exacerbations in the first 30 days (Grade 2B), but recommending against use beyond 30 days (Grade 1A) 6, 1
• A Cochrane systematic review demonstrating no difference in treatment failure, relapse, or adverse events between short-duration (≤7 days) and longer-duration (>7 days) courses 4

Clinical Decision Algorithm

1. Assess oral intake capability: Can the patient swallow and tolerate oral medications?

   • Yes → Prescribe oral prednisone 30–40 mg once daily for 5 days 1, 3
   • No → Administer IV hydrocortisone 100 mg (or methylprednisolone 40 mg IV every 6–8 hours) 1, 3

2. Initiate concurrent therapy:

   • Short-acting β₂-agonist (albuterol 2.5–5 mg) plus short-acting anticholinergic (ipratropium 0.25–0.5 mg) via nebulizer every 4–6 hours 1, 2
   • Antibiotics for 5–7 days if sputum purulence is present with either increased dyspnea or increased sputum volume 1, 2

3. Discontinue corticosteroids after 5 days without tapering 1

Patient Selection Considerations

Blood eosinophil count ≥2% predicts better response to corticosteroids (treatment failure rate 11% vs. 66% with placebo), but current guidelines recommend treating all COPD exacerbations requiring emergent care regardless of eosinophil levels. 1 Patients with blood eosinophil count <2% may have less benefit but should still receive corticosteroids. 1

Common Pitfalls to Avoid

• Do not default to intravenous administration for all hospitalized patients—this increases costs and adverse effects without improving mortality, readmission rates, or treatment failure. 1, 3
• Do not extend therapy beyond 5–7 days—longer courses are associated with increased rates of pneumonia-associated hospitalization and mortality without additional benefit. 1, 4, 7
• Do not use systemic corticosteroids for preventing exacerbations beyond 30 days after the initial event—no evidence supports long-term use, and risks (infection, osteoporosis, adrenal suppression) far outweigh any benefits. 6, 1
• Do not taper the 5-day prednisone course—stop abruptly after day 5, as short courses do not cause hypothalamic-pituitary-adrenal axis suppression. 1
• Do not use intravenous methylxanthines (theophylline/aminophylline)—they increase side effects without added benefit. 1, 2, 3

Adverse Effects to Monitor

Short-term adverse effects of systemic corticosteroids include:

• Hyperglycemia (odds ratio 2.79) 1
• Weight gain 6, 1
• Insomnia 6, 1
• Worsening hypertension (particularly with IV administration) 1

The 5-day oral regimen minimizes these risks compared to longer or intravenous courses. 1, 4, 7