Limitations of this study were its observational design and use of claims data that did not allow the investigators to adjust for clinical findings. This study also excluded patients admitted to the intensive care unit, so these findings should not be applied to this population. These studies, in addition to the high bioavailability of corticosteroids and the vast literature supporting the efficacy of corticosteroids in asthma exacerbations, provide evidence to support the use of low-dose oral corticosteroids for the treatment of patients hospitalized for AECOPD who are not admitted to the intensive care unit.
Although low-dose oral corticosteroids are recommended for AECOPD, systemic exposure predisposes patients to a significant adverse-effect profile. Adverse effects, such as hyperglycemia, myopathy, osteoporosis, thinning of the skin, and posterior subscapular cataract formation, more than any other factor, are most influenced by cumulative steroid dose. Those with frequent exacerbations are of particular concern, as they receive multiple courses of corticosteroid treatment and often higher-dose regimens to control acute exacerbations.
As an alternative to systemic steroids, nebulized corticosteroids have minimal bioavailability, negligible systemic absorption, and minimal systemic adverse effects. The primary end point was change in postbronchodilator FEV 1 at 72 hours.
Clinical success was predefined as an increase in FEV 1 of at least 0. Rates of adverse events were similar in all three groups. In summary, nebulized budesonide and prednisone improved airflow limitation versus placebo. Gunen et al also evaluated nebulized budesonide as an alternative to systemic corticosteroids.
Improvement during day hospitalization was compared with exacerbation and hospitalization rates postdischarge. Similar to the previous study, the recovery rate in terms of both spirometry and arterial blood-gas results did not differ between the nebulized budesonide and systemic prednisone group. However, patients in the systemic prednisolone group did experience a significant upward trend in blood glucose.
Although GOLD guidelines now list nebulized budesonide as an alternative yet expensive option to oral corticosteroids, larger studies are needed to confirm the long-term impact of clinical outcomes of nebulized corticosteroids for AECOPD, as well as to differentiate nebulized steroid choice and optimal dosage. COPD is a complex and progressive disease associated with significant morbidity and mortality. Due to its continuously increasing social and economic burden, significant attention is being paid to the optimal management of the disease and its associated exacerbations.
Based on the current body of evidence Table 2 , corticosteroids remain a standard of care for AECOPD secondary to their documented efficacy in improving airflow and gas exchange increasing FEV 1 and PaO 2 , as well as improving dyspnea, hastening recovery, and reducing length of hospitalization and rate of relapse at 30 days. Oral corticosteroids remain preferable to IV corticosteroids, both in terms of cost and ease of administration.
This logic is reflected in all major guidelines. Until further data are available, the use of nebulized corticosteroids should be reserved for the least severe exacerbations. Despite a lack of large randomized controlled trials, mounting evidence now suggests a shorter treatment duration of corticosteroids may be beneficial in comparison to the previously recommended extended to day course of therapy.
In particular, a recently published randomized, double-blind, placebo-controlled trial found that a 5-day course of systemic corticosteroids was noninferior to the traditional day treatment regimen, in time to exacerbation recurrence. Given these data, it is likely many patients are unnecessarily exposed to the adverse effects of corticosteroids with extended treatment durations.
Although clinical judgment must ultimately play a role in determining the appropriate use and most optimal regimen of corticosteroids in the treatment of AECOPD, we advocate the use of an oral corticosteroid 40 mg of prednisone or equivalent for 5 days in patients experiencing AECOPD severe enough to seek emergent care.
Despite AECOPD being one of the most common causes of hospital admission, head-to-head data comparing corticosteroid selection and dose are lacking. Future research should continue to look for opportunities to use the lowest effective corticosteroid dose and duration possible. The other authors report no conflicts of interest in this work. No additional funding was used in the preparation of the manuscript.
National Center for Biotechnology Information , U. Published online May 3. Author information Copyright and License information Disclaimer. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed. This article has been cited by other articles in PMC. Materials and methods Literature was identified through PubMed Medline —February and Embase —February utilizing the search terms corticosteroids, COPD, chronic bronchitis, emphysema, and exacerbation.
Keywords: chronic obstructive pulmonary disease, exacerbation. Introduction Chronic obstructive pulmonary disease COPD is a debilitating chronic condition of airflow limitation characterized by abnormal inflammation that is not fully reversible and is progressive in nature. Current guideline recommendations Although head-to-head comparison data are limited for evaluating corticosteroid selection and dose efficacy, all major guidelines recommend low-dose oral corticosteroids for exacerbations of COPD severe enough to warrant emergent treatment Table 1.
Open in a separate window. Materials and methods A search of PubMed Medline and Embase —February was performed without limitations using the search terms corticosteroids, COPD, chronic bronchitis, emphysema, and exacerbation. Efficacy of systemic corticosteroids Early clinical trials evaluating the efficacy of systemic corticosteroids in the treatment of COPD offered conflicting results.
Duration of therapy Following clinical trials documenting the efficacy of systemic corticosteroids in the treatment of AECOPD, studies were conducted in an attempt to establish the optimal treatment duration. Route of administration Intravenous versus oral administration Current guidelines for the management of COPD recommend low-dose oral corticosteroids for the treatment of exacerbations.
Inhaled corticosteroids Although low-dose oral corticosteroids are recommended for AECOPD, systemic exposure predisposes patients to a significant adverse-effect profile. Conclusion COPD is a complex and progressive disease associated with significant morbidity and mortality. Table 2 Summary of select clinical trials for systemic corticosteroids compared with placebo. References 1.
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Clinical Question Are shorter courses of systemic corticosteroid therapy as safe and effective as conventional, longer courses for patients with exacerbations of chronic obstructive pulmonary disease COPD? Evidence-Based Answer Treatment of acute exacerbations of COPD with a shorter course of systemic corticosteroids seven or fewer days is likely to be as effective and safe as treating with longer courses more than seven days.
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