Steroids for COPD: Less Is Probably More

May 8, 2014

Steroids for COPD: Less Is Probably More

  1. Patricia Kritek, MD

Patients with chronic obstructive pulmonary disease exacerbations who require intensive care admission do better with low-dose steroids.

  1. Patricia Kritek, MD

A 2010 observational study suggested that relatively low-dose oral corticosteroids were as good as — or better than — high-dose parenteral steroids in hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations, but intensive care unit (ICU) patients were excluded from that study (NEJM JW Gen Med Jun 24 2010). Whether these results can be extrapolated to patients admitted to ICUs is unclear.

Researchers evaluated 17,239 patients (77% older than 60; 31% tobacco users) with COPD exacerbations who were admitted to ICUs at 473 U.S. hospitals. Nearly one third of patients received noninvasive ventilation; 15% were intubated. Almost all patients received antibiotics and bronchodilators. Methylprednisolone doses were categorized as either high (>240 mg) or low (≤240 mg), based on total methylprednisolone administered on hospital day 1 or 2; 11,083 patients (64%) received high doses.

Patients in the two groups were matched by propensity scoring. After adjusting for unbalanced covariates, the groups had similar in-hospital mortality. Compared with high-dose treatment, low-dose treatment was associated with shorter ICU and hospital lengths of stay, lower hospital costs, and shorter duration of mechanical ventilation. Low-dose patients were less likely to require insulin therapy or develop fungal infections.


This study strongly suggests that a moderate dose of steroids is more than adequate to treat ICU patients with severe COPD exacerbations. I would feel comfortable treating such patients with <240 mg of methylprednisolone (i.e., 80 mg to 160 mg), but a randomized trial is necessary to determine optimal dosing and duration of steroids.

Editor Disclosures at Time of Publication

  • Disclosures for Patricia Kritek, MD at time of publication Editorial boards ACP Medicine; New England Journal of Medicine


Reader Comments (1)

John GILBERT Physician, Family Medicine/General Practice, Ireland

As an enthusiast for diagnosing and treating asthma and COPD for the last 30 years, it is with interest that I have watched the fashions change. My own practice with middle aged and elderly patients, at first presentation or with an exacerbation, has been to treat with oral prednisolone 30 mg daily for 1-2 weeks. In the case of first presentation, it establishes whether there is any reversibility. Usually there is. I have been unhappy with the popular view of the last 10 years that only long-acting bronchodilators were required. Many of my patients remained on inhaled steroids for the reason that reversibility was revealed.

However, I never needed to use 10 times the dose and only very rarely did anyone need to go to hospital.

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