X2.2.2 Systemic glucocorticoids for treatment of exacerbations

Systemic glucocorticoids reduce the severity of and shorten recovery from acute exacerbations (Walters et al., 2009) [evidence level I]

A meta-analysis of 11 studies found that systemic glucocorticoid treatment was associated with a significantly lower 30 day treatment failure rate (NNT = 10, 95% CI 7 to 16). (Walters et al., 2009) Systemic glucocorticoids significantly decreased hospital stay (mean difference = -1.22 days, 95%CI -2.26 to -0.18), improved FEV₁ at early and end of treatment time points, decreased breathlessness and improved arterial blood gases. There was an increased likelihood of an adverse event with systemic glucocorticoids (NNH = 5, 95% CI 4 to 9), although most of these were minor in nature.

The optimal dose, route and duration of systemic glucocorticoid treatment have not been established. Oral glucocorticoids are recommended, not only, for their ease of administration, but also as there is no evidence intravenous administration has a more rapid effect and may be less effective. A pharmacoepidemiological cohort study (Lindenauer et al., 2010) [evidence level III-2] found the risk of treatment failure was significantly lower for those treated with oral compared to intravenous glucocorticoids, odds ratio 0.84 (95% CI 0.75, 0.95). For oral glucocorticoid treatment a dose of 30 – 50 mg of prednisolone or equivalent appears adequate. There is no evidence that prolonging treatment beyond two weeks provides additional benefit, and tapering of treatment is not necessary for courses of systemic glucocorticoids up to this duration.

Patients on long-term oral steroid therapy (> 7.5 mg prednisolone daily for more than 6 months) are at risk of developing osteoporosis. Prevention and treatment of ster­oid-induced osteoporosis should be considered.