A Cochrane review included 16 studies comparing systemic corticosteroid with placebo, with a total of 1787 subjects. 13 studies contributed data to the analyses (n = 1 620). Systemic corticosteroids significantly reduced the risk of treatment failure compared with placebo (OR 0.48, 95% CI 0.35 to 0.67; 9 studies, n = 917, median treatment duration 14 days; NNT = 9, 95% CI 7 to 14). The rate of relapse by one month was lower in patients treated with systemic corticosteroids (HR 0.78; 95% CI 0.63 to 0.97, 2 studies, n = 415). Mortality up to 30 days was not reduced by treatment with systemic corticosteroid (OR 1.00; 95% CI 0.60 to 1.66; 12 studies, n = 1 319). FEV1, measured up to 72 hours, showed significant treatment benefits (mean difference [MD] 140 ml; 95% CI 90 to 200; 7 studies; n = 649); however, this benefit was not observed at later time points. The likelihood of adverse events increased with corticosteroid treatment (OR 2.33; 95% CI 1.59 to 3.43; NNH for one extra adverse effect = 6, 95% CI 4 to 10). The risk of hyperglycaemia was significantly increased (OR 2.79; 95% CI 1.86 to 4.19). For general inpatient treatment, duration of hospitalisation was significantly shorter with corticosteroid treatment (MD –1.22 days; 95% CI –2.26 to –0.18; 4 studies, n=480), with no difference in length of stay the intensive care unit (ICU) setting. Comparison of parenteral versus oral treatment showed no significant difference in the primary outcomes of treatment failure, relapse or mortality or for any secondary outcomes (3 studies, n= 239).
Another Cochrane review comparing the efficacy of shorter (≤ 7 days) and longer (> 7 days) duration systemic corticosteroid treatment in acute COPD exacerbations included 8 studies with a total of 582 participants (mean ages from 65 to 73 years). Short course treatment varied between 3 and 7 days and longer duration 10 to 15 days. Oral prednisolone was used in 5 studies and intravenous corticosteroid treatment in 2 studies. There was no significant difference between shorter and longer treatment duration in the risk of treatment failure (OR 0.72, 95% CI 0.36 to 1.46; 4 studies, n=457), in risk of relapse (a new event) (OR 1.04, 95% CI 0.70 to 1.56; 4 studies, n=478), in length of hospital stay (MD -0.61 days, 95% CI -1.51 to 0.28; 3 studies, n=421), in lung function at the end of treatment (MD FEV1 -0.04 L, 95% CI -0.19 to 0.10, I2=58%; 4 studies, n=187), nor in the likelihood of an adverse event (OR 0.89, 95% CI 0.46 to 1.69; 5 studies, n=503). Time to the next COPD exacerbation did not differ in one large study that was powered to detect non-inferiority and compared 5 days versus 14 days of systemic corticosteroid treatment over 6 months of follow-up (HR 0.95, 95% CI 0.66 to 1.37; 1 study, n=311).
In a randomized, placebo-controlled, double-blinded multicenter trial in 5 Swiss teaching hospitals, 314 patients presenting to the emergency department with acute COPD exacerbation were randomized to receive 40 mg of prednisone daily for either 5 or 14 days. 289 (92%) of the patients were admitted to the hospital. 311 patients were included in the intention-to-treat analysis. Main outcome measure was time to next exacerbation within 180 days. Reexacerbation rates were 37.2% (95% CI, 29.5% to 44.9%) in the short-term group and 38.4% (95% CI, 30.6% to 46.3%) in the conventional group (difference –1.2%, 95% CI –12.2% to 9.8%). The median time to reexacerbation was 43.5 days (interquartile range [IQR], 13 to 118) in the short-term and 29 days (IQR, 16 to 85) in the conventional group. There was no difference between groups in time to death, the combined end point of exacerbation, death, or both and recovery of lung function. In the conventional group, mean cumulative prednisone dose was significantly higher (793 mg [95% CI, 710 to 876 mg] vs 379 mg [95% CI, 311 to 446 mg]), but treatment-associated adverse reactions did not occur more frequently. 5-day treatment with systemic glucocorticoids was deemed noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure.