In Patients with Acute Exacerbation of COPD, 5-Day Course of Prednisone Is as Effective as 14-Day Course for Reducing Re-exacerbation

EBM Focus - Volume 8, Issue 24

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Reference: JAMA 2013 Jun 5;309(21):2223, (level 1 [likely reliable] evidence)

For patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), international guidelines recommend a 10-14 day course of oral corticosteroids (GOLD 2013 Feb 13 PDF). Some data suggest that a shorter steroid course may be effective, but existing evidence is inconclusive (Cochrane Database Syst Rev 2011 Oct 5;(10):CD006897). The REDUCE trial compared the efficacy of a 5-day corticosteroid course to the recommended treatment duration for patients presenting to the emergency department with acute COPD exacerbations.

A total of 314 patients > 40 years old (mean age 70 years) presenting to emergency department with an acute COPD exacerbation were randomized to oral prednisone treatment (40 mg/day) for 5 days vs. 14 days and were followed for 6 months. All patients received methylprednisolone 40 mg IV on the first day, and oral prednisone treatment began on the second day. Patients also had broad-spectrum antibiotics for 7 days plus inhaled and nebulized short-acting bronchodilator 4-6 times daily while hospitalized, and during follow-up they had inhaled glucocorticoids, beta-2 agonists, and tiotropium. All patients had a history of ≥ 20 pack-years of cigarette smoking.

There were no significant differences in the rates of re-exacerbation in either intention-to-treat (35.9% with 5-day course vs. 36.8% with 14-day course) or per-protocol analyses (36.7% vs. 38.3% in analysis of 296 patients). The median time to re-exacerbation was 43.5 days with the 5-day course vs. 29 days with the 14 day course, and 5-day treatment was associated with significantly reduced cumulative steroid doses (mean 379 mg vs. 793 mg, p < 0.001). In analysis of 289 patients (92%) who were admitted to the hospital, 5-day treatment was associated with shorter hospital stay (median 8 days vs. 9 days, p = 0.04). There were no significant differences in mortality, need for mechanical ventilation, or adverse events.

For more information, see the Acute exacerbation of COPD topic in DynaMed.