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NIHR Signal One week of steroids may be as effective as two weeks in managing severe COPD

Published on 10 July 2018

doi: 10.3310/signal-000616

A shorter course of steroids lasting 3 to 7 days appears as effective as the recommended 7 to 14-day standard treatment for managing a flare-up of severe chronic obstructive pulmonary disease.

This update to an earlier Cochrane review looked at randomised clinical trials comparing a short course (7 days or fewer) with a longer course (7 to 14 days) of steroids given by mouth or injection. All participants had been admitted to hospital, but none required mechanical ventilation.

The evidence suggests that shorter courses of steroids could be given to people with severe chronic obstructive pulmonary disease where there are concerns about side effects. However, the research was limited by small study sizes and including only 582 people in total. Further research is needed to determine the optimum duration of steroid treatment in flare-ups of mild or moderate chronic obstructive pulmonary disease.

  •   Medicines, Respiratory disorders, Acute and general medicine
One week of steroids may be as effective as two weeks in managing severe COPD

Why was this study needed?

Chronic obstructive pulmonary disease (COPD) is a group of lung diseases commonly associated with smoking that cause breathing difficulty. The World Health Organization estimates that 64 million people have COPD and that it will become the third leading cause of death worldwide by 2030.

Sudden worsening symptoms (exacerbations) occur with COPD and are a cause of hospitalisation. Frequent exacerbations contribute to a progressive decline in lung function.

The recommended treatment for flare-ups includes a course of corticosteroids given by mouth or injection (not inhaled) for between 7 and 14 days. However, prolonged or frequent use of steroids can cause side effects including fluid retention, high blood pressure, diabetes and osteoporosis.

This analysis aimed to assess whether a shorter course of steroids is as effective at treating COPD flare-ups as the longer course.

What did this study do?

This systematic review and meta-analysis pooled data from eight randomised controlled trials of 582 people with severe or very severe COPD.

All participants had been admitted to hospital, but the study did not include people who required assisted ventilation. The average age was between 65 and 73 years old, and most participants were male. None of the studies were from the UK.

Overall, the evidence was graded as moderate in reliability because of the small sample size and wide range of results. The five studies used in the main analysis were considered to be at low risk of bias. The inclusion of a new, well-conducted, study of 296 people reporting since the evidence was last reviewed in 2011 increased the reviewers’ confidence in the results.

What did it find?

  • There was no significant difference in the likelihood of treatment failure (the need for additional treatment) between the short and longer course of steroids (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.36 to 1.46; four studies, 457 participants). The wide margin of error, though, means there is still some uncertainty about this.
  • There was also no difference between treatments in the likelihood of people suffering a new flare-up during the 14 to 180 days follow-up period (OR 1.04, 95% CI 0.7 to 1.56; four studies, 478 participants).
  • One of the side effects from steroid treatment is diabetes. Two studies with moderate-quality data showed no difference in the likelihood of developing high blood sugar between treatment durations (OR 0.99, 95% CI 0.64 to 1.53; 345 people). Low-quality data from five studies also showed no difference in a range of other drug side effects (OR 0.88, 95% CI 0.46 to 1.69; 503 people).
  • Information on quality of life, an important outcome for people with COPD, was limited as it was only measured in one study.

What does current guidance say on this issue?

NICE guidelines published in 2010 on managing COPD include the following key recommendations with regards to steroid treatment of flare-ups (exacerbations):

In the absence of significant contraindications, oral corticosteroids should be used

  • in conjunction with other therapies, in all patients admitted to hospital with an exacerbation of COPD
  • in patients in the community who have an exacerbation with a significant increase in breathlessness which interferes with daily activities
  • for no longer than 14 days as there is no advantage in prolonged therapy

What are the implications?

This updated review reinforces the existing evidence that a short course of steroids may be just as good as a longer course at treating flare-ups in people with severe or very severe COPD.

There is currently variation in the duration of steroid treatment used for COPD flare-ups in clinical practice. This is likely to continue due to individual factors and response to steroids. Though the review is based on small numbers of people, it does provide some evidence that if there has been an adequate response, the steroids could be stopped sooner.

Citation and Funding

Walters JA, Tan DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018;3:CD006897.

This review was funded by the Breathe Well Centre of Research Excellence, University of Tasmania, Australia and the National Health and Medical Research Council, Australia.

Bibliography

NHS Choices. Chronic obstructive pulmonary disease (COPD). London: Department of Health and Social Care; updated 2018.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

WHO. Burden of COPD. Geneva: World Health Organization; accessed May 2018.

Expert commentary

Systemic corticosteroids are recommended for severe acute exacerbations of chronic obstructive pulmonary disease (COPD), but the duration of this treatment varies from one to two weeks in duration. Since systemic corticosteroids have long-term adverse effects, such as osteoporosis, it is important to use the lowest effective treatment duration.

This Cochrane review shows that shorter courses (7 days) are as effective as longer courses (up to 14 days) in terms of the frequency of relapse, duration of hospital admission and recurrence of exacerbations, although the quality of the evidence used was poor in most studies.

The studies included patients with severe COPD who were hospitalised and did not consider duration of oral steroids used in moderate disease or patients treated at home.

Peter Barnes, NHLI, Imperial College London