Steroids in Asthma and COPD

Patient Case

• The team gets a call that there is a 36-year-old that present with SOB brought in by EMS and is currently displaying increased work of breathing and in acute distress
• Patient has been out of her albuterol inhaler for 7 days
• The provider has asthma exacerbation at the top of the differential diagnosis
• Respiratory therapy has started albuterol and ipratropium and the team asks should the team start steroids

Should we use steroids? Which pharmacologic agent should we use? What dose should we use?

Comparison of systemic corticosteroids used in asthma and COPD exacerbations.

What are the benefits of corticosteroids?

• Asthma: increase in peak expiratory flow rate (PEFR)
• COPD: decreased duration of mechanical ventilation, NIV failures, decreased hospital LOS, improvement in lung function and dyspnea over the first 72 hours

What route to administer corticosteroids in an asthma/COPD exacerbation?

• Current guidelines for the management of COPD and asthma recommend low-dose oral corticosteroids for the treatment of exacerbations
• Comparisons of oral prednisone and intravenous corticosteroids have not shown differences in the rate of improvement of lung function or in the length of the hospital stay

What is the optimal duration of corticosteroid therapy?

• Asthma: guidelines recommend 5-10 days of therapy
• COPD: GOLD guidelines recommend no longer than 5-7 days

How to manage corticosteroids in discharged patients

• Systemic corticosteroids improve outcomes in both asthma and COPD exacerbations: in asthma they increase peak expiratory flow rate (PEFR), and in COPD they reduce duration of mechanical ventilation and NIV failures, shorten hospital length of stay, and improve lung function and dyspnea over the first 72 hours.
• Guidelines recommend low-dose oral corticosteroids for exacerbations; oral prednisone and intravenous corticosteroids have not shown differences in rate of lung-function improvement or length of hospital stay.
• Optimal duration is short: 5 to 10 days for asthma, and no longer than 5 to 7 days for COPD per GOLD guidelines.
• At discharge, options include oral prednisone 40 to 60 mg (or equivalent) once daily for 5 to 10 days, or a single pre-discharge IM depot dose (dexamethasone 10 mg, triamcinolone diacetate 40 mg, or methylprednisolone 160 mg).

Micromedex [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved April 1, 2019, from http://www.micromedexsolutions.com/

Walters JA, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897. doi: 10.1002/14651858.CD006897.pub4.

Lazarus SC, et al. Clinical practice. Emergency treatment of asthma. N Engl J Med. 2010 Aug 19;363(8):755-64

Woods JA, et al. Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2014 May 3;9:421-30

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org

Vogelmeier CF, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med. 2017 Mar 1;195(5):557-582.

Walls. R, et al. (2018). Rosen’s emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.

Niewoehner DE, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941-1947.