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Although randomized trials have demonstrated benefits of systemic corticosteroids in patients with chronic obstructive pulmonary disease (COPD) exacerbations, those studies used various doses and durations of steroid therapy, which has led to guideline differences and practice variation. The 2012 GOLD guidelines recommend a 10- to 14-day course of systemic corticosteroids (30–40mg prednisone) for COPD exacerbations (JW Gen Med Sep 13 2012).
In a Swiss study, investigators randomized 314 patients (>85% with severe or very severe airflow limitation; 92% admitted to hospital; baseline mean forced expiratory volume in 1 second [FEV1], 31%) with acute COPD exacerbations to receive 5-day or 14-day courses of oral prednisone (40 mg daily). Intent-to-treat analysis revealed no difference in repeat exacerbation within 6 months (36% vs. 37%), time to repeat exacerbation, death from any cause, or need for mechanical ventilation. Adverse events were similar in the two groups, but median length of hospital stay was significantly shorter in the 5-day group (8 vs. 9 days).
Leuppi JD et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013 Jun 5; 309:2223. (http://dx.doi.org/10.1001/jama.2013.5023)
Sin DD and Park HY. Steroids for treatment of COPD exacerbations: Less is clearly more. JAMA 2013 Jun 5; 309:2272. (http://dx.doi.org/10.1001/jama.2013.5644)
Comment
Low-dose, short-course corticosteroids appropriately manage chronic obstructive pulmonary disease exacerbations without leading to short- or long-term adverse events. This result is all the more impressive because most patients had severe or very severe baseline disease. As the editorialists note, less is definitely more when it comes to steroids and COPD exacerbations, and most patients — including hospitalized patients — should be managed with 5-day courses of steroid therapy.