ASK DIS: When is it Indicated to Start Corticosteroids in COPD Exacerbations?

Rationale:

Studies concluded that systemic (oral or intravenous) glucocorticoids reduced treatment failure
increased the rate of improvement in lung function and symptoms
more rapid increase in FEV₁, fewer withdrawals, and a significantly shorter hospital stay
benefits of glucocorticoids appear to be greatest in the first 72 hours after administration

Outpatient exacerbations:

small, but significant clinical effect
Patients who received prednisone (40mg for 10 days) were less likely to return with increasing dyspnea within 30 days (27 versus 43 percent). In addition to a lower rate of relapse, prednisone therapy was associated with decreased dyspnea

Hospitalised Patients:

Adverse effect of short term therapy:

Only hyperglycemia was more common in the glucocorticoid-treated groups
Patients who received the eight-week course of glucocorticoids had a tendency to have more severe infections, particularly pneumonia
Patients treated with short-term, high-dose glucocorticoids for septic shock have a significantly increased risk of secondary bacterial infection and an increased mortality

Selection criteria:

Currently, no criteria have been established for deciding which patients benefit most from corticosteroid therapy.
Thus, all patients without serious contraindications should receive systemic corticosteroids for severe exacerbations of COPD

Severity of exacerbation	Description
Mild	Can be controlled with an increase in dosage of regular medications
Moderate	Requires treatment with systemic corticosteroids or antibiotics
Severe	Requires hospitalization or evaluation in the emergency department

Duration:

No more than two weeks of therapy are needed; shorter courses may achieve adequate outcomes but need further study.
Extending the duration of therapy beyond 2 weeks and using higher doses does not confer additional benefits, but can increase the risk of short-term side effects such as hyperglycemia and insomnia
If steroid therapy is continued for longer than 2 weeks, a tapering schedule should be employed to avoid hypothalamic-pituitary-adrenal axis suppression
As a rough guide, full dose therapy (eg, prednisone 40 mg daily) is given for 5 to 14 days

Treatment:

a compromise approach to dosing; administer one or more high doses (eg, methylprednisolone 80 to 125 mg) in the first 24 hours with rapid conversion to lower-dose therapy (prednisone 40 to 60 mg per day) if the patient is improving.
IV glucocorticoids are typically administered to patients who present with a severe exacerbation, who respond poorly to oral glucocorticoids, unable to take oral medication, or who may have impaired absorption due to decreased splanchnic perfusion (eg, patients in shock).
A reasonable alternative is to use a regimen of prednisone or its equivalent in doses of 30 to 60 mg per day for the duration of therapy

futher reading:

References:

ASK DIS