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Different Durations of Corticosteroid Therapy for COPD Exacerbations | AAFP
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❿Exacerbation of copd prednisolone.COPD exacerbations in general practice: variability in oral prednisolone courses
Nearly every GP gave a continuous regimen of prednisolone 30 mg a day for patients without or with diabetes table 2 and 3 ; Figure 1 and 2. Among GPs there were large differences in duration of treatment. Although a seven- day course was most common, courses of five, ten, or fourteen days were also frequently prescribed in patients with or without diabetes.
A five- day course was especially prescribed in case of a mild exacerbation. In more severe exacerbations, GPs preferred a course of seven, ten, or fourteen days. Patients with and without diabetes mellitus were compared.
This study shows that GPs in the Netherlands rather uniformly prescribe a daily dose of 30 mg prednisolone in the treatment of COPD exacerbations. There is hardly any difference between GPs in dosage of treatment and with that they strictly seem to follow the guidelines. On the other hand GPs differed notably in duration of treatment. These differences in duration of treatment increased in more serious situations.
A small number of GPs prescribed the same regimen in all case scenarios. Treatment was often adjusted to exacerbation and disease severity. This even determined the choice between treatment with or without consultation of a pulmonologist. Of note, few GPs adjusted their treatment to the presence of diabetic co-morbidity. GPs reported the important influence of an earlier, successful individual treatment experience as well as the patients wish on choice of treatment regimen.
It is conceivable that GPs management working hours, local appointments, coded prescriptions and prescribing according to an electronic prescription system as well as regional, national and international guidelines play a role in prescribing a particular treatment regimen. These guidelines are evidence based, comprehensive, and the conclusions are published for all diseases in the same format.
Currently guidelines are available for 99 different diseases among which COPD. The level of compliance with the guidelines is high even though there is hardly any evidence to support it. The regimen 30 mg prednisolone for days is also common internationally table 4 [ 2 , 7 — 21 ]. A couple of studies comparing corticosteroid treatment with placebo treatment, showed a number of beneficial effects on FEV1 improvement, days of hospitalisation [ 7 , 8 ] and time to second exacerbation [ 9 ].
Only two studies were found regarding treatment duration [ 8 , 10 ]. In the first study, a course of 8 weeks was no more effective than a course of two weeks [ 8 ]. In the second study, a course of 10 days was more effective than a course of three days [ 10 ].
No head to head comparisons of different dosages were found. Randomised clinical trials RCTs using higher dosages did not achieve better results than RCTs using lower dosages [ 7 — 9 ]. The current policy to reject the tapering regimen is based on an old study in patients with an asthma exacerbation [ 16 ].
It is interesting that few studies showed some beneficial effects of inhalation corticosteroids, whether or not combined with a long acting betaagonist, in comparison with prednisolone [ 12 — 15 ]. With all these uncertainties it is not surprising that there is no guidance regarding how to adjust treatment to exacerbation and disease severity or to the presence of diabetic co-morbidity. Many GPs tend to prescribe a higher dose or longer treatment duration in case of a severe exacerbation or severe COPD.
However again, evidence based regimes are missing. It is only known that oral prednisolone is not less effective than intravenous prednisolone [ 11 ]. Just like other international guidelines, the Dutch Guideline does not provide guidance how to prescribe in case of diabetic co-morbidity. However, dose and duration of treatment strongly determine the risk of side effects [ 4 ]. In nearly every patient with known diabetes, corticosteroids exacerbate hyperglycaemia [ 22 ]. So, many patients have to deal with steroid induced hyperglycaemia.
This is not without risk. Fluctuations in plasma glucose concentrations have been associated with increased cardiovascular mortality [ 22 ]. Moreover, three or more corticosteroid treatments per year are associated with an odds ratio of 1. The same treatment regimen was routinely applied to patients with or without diabetes mellitus. There is no evidence to support different doses, largely because there is no evidence at all. Perhaps clinicians feel that some loss of glucose control is not as serious as an inadequately treated exacerbation of COPD.
An alternative for patients with diabetes could be to check their glucose levels daily preferably until a couple of days after finishing their treatment. It may be easier for patients on insulin to measure their blood sugar and adjust their insulin accordingly, while those on oral agents have less ability to do so. Apart from hyperglycaemia there are important other side effects of the treatment with corticosteroids: in particular endocrine, neurological, psychiatric, ophthalmic and gastrointestinal side effects.
There are also side effects of the musculoskeletal system, metabolism and electrolyte balance. Dosage and duration of treatment again determine the risk of these side effects [ 4 ].
For most of the side effects it is not exactly known at which dosage they occur. Side effects as fluid retention, hypertension and heart failure can occur directly after starting prednisolone treatment.
Psychiatric disturbances as depression, mania, anxiety, and psychosis may occur within the first week [ 24 ]. Even short term, low dose systemic steroids exposes the patient to the risk of adrenal insufficiency [ 25 ].
A well-known long term complication is osteoporosis [ 26 , 27 ]. Many patients with COPD receive treatment with prednisolone several times a year. The cumulative dose of corticosteroids strongly correlates with vertebral fracture risk due to loss of bone mineral density [ 27 ]. Because of the short term side effects and the possible cumulative risks, total steroid exposition should be kept as low as possible.
In patients with a COPD exacerbation, treatment should be as short as possible with the dosage prednisolone as low as possible. In patients with an asthma exacerbation a short course days of prednisolone has been shown to be effective [ 28 , 29 ]. More research should establish the optimum dose and duration of corticosteroid treatment. Research should also be directed at determining how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity.
Until then the best we can do is to follow the current guideline that recommends prednisolone 30 mg for seven to fourteen days. We did not want to increase the number of questions as this could influence the response rate. Therefore we decided to focus on dose and duration of prednisolone treatment, despite the recommendation of the Dutch guideline to double patient's dose of bronchodilators or to use a combination of two different bronchodilators in case of an non-severe exacerbation.
In summary, a 5-day course of oral prednisolone of 30mg to 50mg is adequate. In patients who have been on oral corticosteroids for longer than 14 days, tapering may be necessary. Prevention and treatment of corticosteroid-induced osteoporosis should be considered. Longer courses of prednisolone may increase mortality and pneumonia Sivapalan There is emerging evidence that blood eosinophil levels can be used as a biomarker to determine which patients require oral corticosteroids for exacerbations of COPD.
A small, single centre, double blind randomised controlled trial used blood eosinophils as a biomarker to determine if prednisolone would be given for an exacerbation of COPD. FDA Resources. Arms and Interventions. Outcome Measures. Eligibility Criteria. Information from the National Library of Medicine Choosing to participate in a study is an important personal decision. Exclusion Criteria: Asthmatic patients defined by a reversible obstructive disease following nebulized bronchodilators, Patients with uncontrolled left heart failure, AECOPD patients with a radiologically documented pneumonia, Systemic corticotherapy within 30 days before screening, contra-indication to corticosteroids active gastroduodenal ulcer, uncontrolled sepsis, etc.
Contacts and Locations. Information from the National Library of Medicine To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor. Please refer to this study by its ClinicalTrials. Bourguiba Monastir, Tunisia, Bourguiba Monastir. More Information. Corticosteroid administration and treatment failure in acute exacerbation of chronic obstructive pulmonary disease. Steroids in acute exacerbations of chronic obstructive pulmonary disease: are nebulized and systemic forms comparable?
Curr Opin Pulm Med. COPD acute respiratory failure mechanical ventilation non invasive ventilation steroids. National Library of Medicine U.
The number needed to treat to avoid one treatment failure is 9. There is no evidence that treatment with corticosteroids alters mortality. Unlike earlier reviews this review included four papers that compared intravenous corticosteroids with oral corticosteroids and two papers with ventilated patients in ICU. In patients requiring ventilation in ICU, pooled data did not show a reduction in length of stay, duration of ventilation or mortality in those receiving corticosteroids compared with placebo Walters Walters et al concluded that there is no evidence of benefit for intravenous treatment compared with oral treatment with corticosteroids on treatment failure, relapse or mortality.
Hyperglycaemia rates were higher with intravenous corticosteroids. With regards to duration of treatment, a meta-analysis by Walters et al Walters concluded that five days of oral corticosteroids is likely to be sufficient [evidence level I]. In summary, a 5-day course of oral prednisolone of 30mg to 50mg is adequate. In patients who have been on oral corticosteroids for longer than 14 days, tapering may be necessary.
Prevention and treatment of corticosteroid-induced osteoporosis should be considered. Longer courses of prednisolone may increase mortality and pneumonia Sivapalan There is emerging evidence that blood eosinophil levels can be used as a biomarker to determine which patients require oral corticosteroids for exacerbations of COPD. A small, single centre, double blind randomised controlled trial used blood eosinophils as a biomarker to determine if prednisolone would be given for an exacerbation of COPD.
In the standard arm, all patients received prednisolone. The prednisolone dose was 30mg for 14 days and both groups received oral antibiotics. There was no difference in treatment failure or health status between the biomarker and standard groups Bafadhel Patients had blood eosinophil levels measured at the time of COPD exacerbation. The trial designs had considerable heterogeneity. Further, larger studies with long term follow up are required before any firm recommendations can be made.
Treatment of patients with acute exacerbations of COPD with corticosteroids is a common practice. The evidence shows that this significantly improves lung. Treatment of acute exacerbations of COPD with a shorter course of systemic corticosteroids (seven or fewer days) is likely to be as. Exacerbations of COPD are associated with a more rapid decline in lung the GOLD guidelines suggested the use of prednisolone 30 to 40 mg. Treatment of acute exacerbations of COPD with a shorter course of systemic corticosteroids (seven or fewer days) is likely to be as. In patients with a COPD exacerbation, treatment should be as short as possible with the dosage prednisolone as low as possible. In patients with. A five- day course was especially prescribed in case of a mild exacerbation. Just like other international guidelines, the Dutch Guideline does not provide guidance how to prescribe in case of diabetic co-morbidity. However, the questionnaire does not concern a sensitive subject. Study Start Date :.Metrics details. The use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based.
However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant.
This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation.
It also investigates the number of general practitioners GPs who adjust their treatment according to the presence of diabetic co-morbidity.
Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity.
A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity. Under normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines.
There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.
Peer Review reports. COPD exacerbations have a profound and long lasting effect on quality of life and the frequency of exacerbations contributes to long term decline in lung function [ 1 ]. Treatment of a COPD exacerbation with oral or parenteral corticosteroids significantly reduces treatment failure, the need for additional medical treatment, and shortens hospital stay. It increases the rate of improvement in lung function and dyspnoea [ 2 ]. However, corticosteroid therapy is associated with undesirable side effects, especially weight gain, insomnia and hyperglycaemias [ 2 , 3 ].
The risk of these side effects depends on dosage and duration [ 4 ]. The question is whether the potential benefits of treatment outweigh their risks. Optimum dosage and duration of treatment are not yet established [ 2 ].
Hospitalized patients all receive systemic treatment with corticosteroids. There is no guidance regarding how to adjust treatment to any co-morbidity. Unclear treatment advice may lead to differences in dosage and duration of treatment with systemic corticosteroids. Because of the side effects, difference in prescribing might be relevant.
Are there differences between general practitioners in the dose and duration of prednisolone treatment in case of COPD exacerbations?
Do dosage and duration of prednisolone treatment depend on exacerbation and disease severity or diabetic co-morbidity? A cross sectional survey using questionnaires was conducted in the Northern part of The Netherlands, distributed randomly over general practitioners GPs and GPs in training between May and June The items of the questionnaire additional file 1 were based on the literature and interviews with four experts.
In order to improve the face and content validity, the concept questionnaire was presented to a number of senior GPs and GP trainees. We presented four case scenarios regarding different patients with an exacerbation of COPD. In case A to D exacerbation-and disease severity increased. An exacerbation was characterized by 'a worsening of patient's condition within a couple of days, representing a worsening of dyspnoea and coughing with or without sputum beyond normal day-to-day variations'.
A severe exacerbation was characterized by dyspnoea at rest, inability to speak in a full sentence, not able to lay flat, respiratory frequency above thirty breaths per minute, heart rate above one hundred twenty beats per minute and the use of accessory respiratory muscles. The questionnaire consisted of semi closed self-completed questions.
Every GP had to give a treatment regimen for each case supposing that the patient was non-diabetic or diabetic, respectively. We choose the co-morbidity diabetes as this has the highest prevalence of the co-morbidities influenced by the use of prednisolone. We created space for comments. Data were analysed by using SPSS Ethical approval was not required.
The study was conducted in May through to December All respondents were working in a general practice with an average of four days per week range 0. Nearly every GP gave a continuous regimen of prednisolone 30 mg a day for patients without or with diabetes table 2 and 3 ; Figure 1 and 2. Among GPs there were large differences in duration of treatment. Although a seven- day course was most common, courses of five, ten, or fourteen days were also frequently prescribed in patients with or without diabetes.
A five- day course was especially prescribed in case of a mild exacerbation. In more severe exacerbations, GPs preferred a course of seven, ten, or fourteen days.
Patients with and without diabetes mellitus were compared. This study shows that GPs in the Netherlands rather uniformly prescribe a daily dose of 30 mg prednisolone in the treatment of COPD exacerbations. There is hardly any difference between GPs in dosage of treatment and with that they strictly seem to follow the guidelines. On the other hand GPs differed notably in duration of treatment.
These differences in duration of treatment increased in more serious situations. A small number of GPs prescribed the same regimen in all case scenarios.
Treatment was often adjusted to exacerbation and disease severity. This even determined the choice between treatment with or without consultation of a pulmonologist. Of note, few GPs adjusted their treatment to the presence of diabetic co-morbidity. GPs reported the important influence of an earlier, successful individual treatment experience as well as the patients wish on choice of treatment regimen. It is conceivable that GPs management working hours, local appointments, coded prescriptions and prescribing according to an electronic prescription system as well as regional, national and international guidelines play a role in prescribing a particular treatment regimen.
These guidelines are evidence based, comprehensive, and the conclusions are published for all diseases in the same format.
Currently guidelines are available for 99 different diseases among which COPD. The level of compliance with the guidelines is high even though there is hardly any evidence to support it. The regimen 30 mg prednisolone for days is also common internationally table 4 [ 2 , 7 — 21 ]. A couple of studies comparing corticosteroid treatment with placebo treatment, showed a number of beneficial effects on FEV1 improvement, days of hospitalisation [ 7 , 8 ] and time to second exacerbation [ 9 ].
Only two studies were found regarding treatment duration [ 8 , 10 ]. In the first study, a course of 8 weeks was no more effective than a course of two weeks [ 8 ]. In the second study, a course of 10 days was more effective than a course of three days [ 10 ]. No head to head comparisons of different dosages were found. Randomised clinical trials RCTs using higher dosages did not achieve better results than RCTs using lower dosages [ 7 — 9 ]. The current policy to reject the tapering regimen is based on an old study in patients with an asthma exacerbation [ 16 ].
It is interesting that few studies showed some beneficial effects of inhalation corticosteroids, whether or not combined with a long acting betaagonist, in comparison with prednisolone [ 12 — 15 ]. With all these uncertainties it is not surprising that there is no guidance regarding how to adjust treatment to exacerbation and disease severity or to the presence of diabetic co-morbidity. Many GPs tend to prescribe a higher dose or longer treatment duration in case of a severe exacerbation or severe COPD.
However again, evidence based regimes are missing. It is only known that oral prednisolone is not less effective than intravenous prednisolone [ 11 ]. Just like other international guidelines, the Dutch Guideline does not provide guidance how to prescribe in case of diabetic co-morbidity. However, dose and duration of treatment strongly determine the risk of side effects [ 4 ]. In nearly every patient with known diabetes, corticosteroids exacerbate hyperglycaemia [ 22 ].
So, many patients have to deal with steroid induced hyperglycaemia. This is not without risk. Fluctuations in plasma glucose concentrations have been associated with increased cardiovascular mortality [ 22 ]. Moreover, three or more corticosteroid treatments per year are associated with an odds ratio of 1.
The same treatment regimen was routinely applied to patients with or without diabetes mellitus. There is no evidence to support different doses, largely because there is no evidence at all.
Perhaps clinicians feel that some loss of glucose control is not as serious as an inadequately treated exacerbation of COPD. An alternative for patients with diabetes could be to check their glucose levels daily preferably until a couple of days after finishing their treatment.
It may be easier for patients on insulin to measure their blood sugar and adjust their insulin accordingly, while those on oral agents have less ability to do so. Apart from hyperglycaemia there are important other side effects of the treatment with corticosteroids: in particular endocrine, neurological, psychiatric, ophthalmic and gastrointestinal side effects. There are also side effects of the musculoskeletal system, metabolism and electrolyte balance.
Dosage and duration of treatment again determine the risk of these side effects [ 4 ]. For most of the side effects it is not exactly known at which dosage they occur. Side effects as fluid retention, hypertension and heart failure can occur directly after starting prednisolone treatment. Psychiatric disturbances as depression, mania, anxiety, and psychosis may occur within the first week [ 24 ].
Even short term, low dose systemic steroids exposes the patient to the risk of adrenal insufficiency [ 25 ]. A well-known long term complication is osteoporosis [ 26 , 27 ]. Many patients with COPD receive treatment with prednisolone several times a year.
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