2025 Southeastern Residency Conference

Title: Evaluation of Clinical Outcomes in Patients with AECOPD Receiving Systemic Corticosteroids

Authors: Ashley V. Adkins; Rachel Kile

Objective: Assess outcomes of cumulative corticosteroid dosing ≤ 200 mg compared to > 200 mg in patients admitted with or for AECOPD

Self Assessment Question: What is the most recent GOLD guideline-recommended corticosteroid regimen for AECOPD management

Background: 
Systemic corticosteroids have been shown to improve lung function, health-related quality of life,  decrease hospitalization duration, need for mechanical ventilation, treatment failure, readmission rates, and dyspnea in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommends using 40 mg of prednisone equivalent daily for 5 days (200 mg total prednisone equivalents), however, a standard dose of systemic corticosteroids across guidelines does not exist. Optimal doses of systemic corticosteroids for managing AECOPD vary, with prednisone and methylprednisolone commonly used. Both oral and intravenous administration of corticosteroids show similar outcomes regarding treatment failure, relapse, and mortality, with the IV route preferred for severe cases. Similar to dosing, there is no optimal duration of systemic corticosteroids in AECOPD; however, chronic use is generally avoided.

Methods: 
A retrospective review was conducted (n=164) to assess the impact of prednisone equivalent dosing less than or equal to 200 mg vs. greater than 200 mg on AECOPD-related outcomes. Patients aged ≥ 40 years who were hospitalized for AECOPD between August 1, 2023, and July 31, 2024, were included in the initial data analysis. Patients were excluded if they were not admitted, transferred from another facility before admission, had baseline or newly diagnosed comorbid lung conditions, left against medical advice, were admitted for hospice, or used corticosteroids in the past 30 days before admission. The primary outcome evaluated mean length of stay (LOS). Secondary outcomes included need for ICU transfer, respiratory failure, mean blood glucose readings >180 mg/dL,  requirement of rapid-acting insulin, mechanical ventilation, requirement of supplemental oxygen, inpatient mortality, and 30- and 60-day all-cause readmission rates.

Results:
Of the 164 patients with AECOPD included in the initial analysis, 100 patients met inclusion criteria. The included patients were divided into 2 separate arms:  prednisone equivalent dosing ≤ 200 mg (n= 18) vs. > 200 mg (n=82). There were no statistically significant differences between the two arms for baseline characteristics. The primary endpoint showed a statistically significant difference in the mean LOS between the prednisone equivalent dosing ≤ 200 mg vs. > 200 mg (3.56 days vs. 5.56 days, p= 0.0081). There were no statistical differences found between the two arms for secondary endpoints however, there was a numerically significant endpoint, including blood glucose abnormalities >180 mg/dL (27.8% vs. 41.4%). There was a statistically significant difference found between the average total days of inpatient corticosteroid use (3.11 vs. 5.5, p= 0.0029) and the average milligrams of inpatient prednisone equivalents used (149.472 vs. 613.089, p= 0.0001). No statistically significant differences were found between the different corticosteroid types or routes of administration used.

Conclusion:
Eighty-two percent of included patients received cumulative corticosteroid dosing above the GOLD guideline recommendation (> 200 mg prednisone equivalents) without clear evidence showing that conservative dosing ≤ 200 mg prednisone equivalents vs. higher doses > 200 mg prednisone equivalents makes a positive clinical difference on pre-specified outcomes. In conclusion, it is recommended to re-educate providers on the availability of the COPD order set, which limits the use of corticosteroids to GOLD guideline recommendations, and trial a pharmacist-driven intervention report for patients on more than 5 days of corticosteroid therapy when admitted for or with AECOPD. If these changes are implemented, a follow-up assessment would be warranted to compare findings to the same pre-specified outcomes as this review.