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Am Fam Physician. 2019;99(5):295-296

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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). There is no significant difference in adverse effects between shorter and longer courses.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

COPD is a chronic, progressive lung condition resulting in airflow limitations. Patients with COPD are at risk of acute exacerbations, which may present as dyspnea, increased cough, and sputum production. Systemic corticosteroids are a mainstay of treatment, but the necessary duration of treatment is debated. The authors of this review assessed whether a shorter course of systemic corticosteroids (seven or fewer days) was as safe and effective as the more conventional 10- to 14-day course.

This Cochrane review included eight studies and 582 patients.1 Five of the studies, which included 519 patients, were hospital based; the remaining three did not specify location. No studies specified whether patients completed the entire treatment course in the hospital. The mean age of participants was 65 to 73 years, and the proportion who were men ranged from 58% to 84%. The studies were conducted in Switzerland, Egypt, Bangladesh, China, Turkey, Thailand, and New Zealand. Only three studies discussed co-interventions, which varied among the studies but included oxygen, inhaled or nebulized bronchodilators, inhaled steroids, theophylline, and, in one study, a histamine H2 antagonist. When co-interventions were specified, they were applied to all participants. Two of the studies treated all patients with antibiotics, although details were not provided. One study used antibiotics only if indicated by certain clinical features. The effect of co-interventions was not included in this review.

Five studies used oral prednisolone, one study used intravenous methylprednisolone, and two studies used a combination of oral and intravenous corticosteroids. Shorter courses of corticosteroids ranged from three to seven days of treatment; longer courses ranged from 10 to 15 days. This review did not discuss whether three days of treatment is equivalent to other courses of up to seven days of treatment. The studies included only patients with severe to very severe COPD, although the criteria for this were not well-defined or consistent among studies. Three studies used pulmonary function testing diagnostic criteria, but even those criteria were not uniform. Primary outcomes included treatment failure, relapse after treatment, and adverse drug effects.

Treatment failure was assessed in four studies (n = 457), as was relapse (n = 478). Adverse effects that were studied included hyperglycemia (n = 345), hypertension (n = 311), and “other” (n = 503), which included gastrointestinal bleeding, symptomatic gastrointestinal reflux, symptoms of congestive heart failure or ischemic heart disease, sleep disturbance, fractures, or depression. There was no difference in any primary outcomes between patients who were treated with systemic corticosteroids for seven or fewer days and those who were treated for more than seven days. The investigators rated the evidence for primary outcomes as moderate, with imprecision as a reported limiting factor.

As noted, the studies did not specifically address outpatient therapy for COPD exacerbations and excluded patients with mild or moderate COPD. Current guidelines from the Global Initiative for Chronic Obstructive Lung Disease recommend treating acute exacerbations of COPD with oral prednisone, 40 mg per day for five days in most patients.2

The practice recommendations in this activity are available at http://www.cochrane.org/CD006897.

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