Recommended Dose of IV Corticosteroids for COPD Exacerbation?

Question

It seems to be common practice to use very large doses of intravenous (IV) corticosteroids (1-2 mg/kg of methylprednisolone every 6 hours) for a chronic obstructive pulmonary disease (COPD) exacerbation severe enough to require hospital admission. Having been involved recently with 2 nondiabetic patients who experienced disseminated mucormycosis following treatment, I want to know whether there is any evidence base to determine the ideal inpatient dose of IV corticosteroids.

Response from Joseph Li, MD

COPD is a significant health and economic burden in the United States and around the world. More than 5% of the world is afflicted with COPD.^[1] In this modern era of medical miracles, COPD is the only major cause of death in the United States for which both the mortality and morbidity rates are rising.^[2] In 1993, the treatment of COPD represented $24 billion to the healthcare system; over 60% of this cost was directly related to care delivered in the hospital setting.^[3,4]

For such a commonly encountered disease, there is a surprisingly small amount of evidence surrounding the use of corticosteroids in the management of acute exacerbation of COPD. Contrast this to the treatment of acute asthma, a distinctly different clinical entity. The use of systemic corticosteroids in the treatment of acute asthma is not only widespread, but has also been shown to be beneficial.^[5] For decades, clinicians have prescribed corticosteroids for the treatment of acute COPD exacerbation, as an extension of the role of these medications in the treatment of acute asthma. To be fair, it is sometimes difficult to determine whether a given patient with obstructive lung disease has either asthma and/or COPD. In such instances, corticosteroid therapy is appropriately prescribed during an acute exacerbation.

Today, in the United States, it is common for clinicians to treat patients with an acute COPD exacerbation with intravenous methylprednisolone, followed by a tapering course of oral prednisone.^[6] The evidence surrounding this practice comes mainly from a few small studies.^[7,8,9]

The best evidence supporting the use of systemic corticosteroid use for patients hospitalized with COPD exacerbation came from the Systemic Corticosteroids in Chronic Obstructive Pulmonary Disease Exacerbations (SCCOPE) trial.^[10] In this study, patients were randomized into 3 groups: placebo, a 2-week course of systemic corticosteroids, or an 8-week course of corticosteroid treatment. Systemic treatment was 125 mg IV methylprednisolone for 3 days, followed by a tapering course of oral prednisone. The results from participants who received 2 weeks vs 8 weeks of corticosteroid treatment did not differ.

Patients who received corticosteroids had:

A 10% lower rate of treatment failure, at 30 and 90 days; A shorter length of hospital stay; More rapid improvement in forced expiratory volume in 1 second (FEV1); and More hyperglycemia, requiring the addition or change in medication to control blood glucose.

A subsequent smaller study randomized patients with acute COPD exacerbations to placebo vs 30 mg prednisolone x 14 days.

^[11]

Patients treated with prednisolone had a shorter hospital stay and a more rapid increase in FEV

₁

.

These 2 small studies support the use of corticosteroids in the treatment of acute COPD exacerbations. The early increase in FEV

₁

was greatest in the cohort of patients in the SCCOPE trial who received IV methylprednisolone. But this is insufficient evidence for suggesting an optimal dose of corticosteroids when treating an acute exacerbation. Based on data from the SCCOPE trial, there does not appear to be any evidence to support the use of corticosteroids beyond 2 weeks of duration.

^[10]

Again, however, the evidence in this field is inadequate and deserves further study.

Medscape Internal Medicine. 2004;6(1) © 2004 Medscape

Cite this: Joseph Ming Wah Li. Recommended Dose of IV Corticosteroids for COPD Exacerbation? - Medscape - Mar 02, 2004.