COPD guidelines report that systemic corticosteroids are preferred over inhaled corticosteroids in the treatment of exacerbations, but the inhaled route is considered to be an option.
OBJECTIVES:
To conduct a systematic review and meta-analysis regarding the efficacy and safety of inhaled corticosteroids for COPD exacerbations. The second objective was to provide pharmacologic and clinical perspectives of inhaled corticosteroids for COPD exacerbations.
METHODS:
The primary outcome was a change in FEV1 baseline versus the last measured value. Secondary outcomes were a change in (PaO2) and (PaCO2) baselines versus the last measured values; FEV1, PaO2, and PaCO2 at 24 or 72 h; and hyperglycemia.
RESULTS:
Each of the 9 studies included in the meta-analysis was conducted in subjects who were hospitalized and not critically ill. Our meta-analysis indicated that high-dose nebulized budesonide 4–8 mg/d was noninferior to systemic corticosteroids on the change in FEV1 between baseline and the last measured value (mean difference of 0.05, 95% CI −0.01 to 0.12, P = .13) and PaCO2 (mean difference of −1.14, 95% CI −2.56 to 0.27, P = .11) but of inferior efficacy for PaO2 changes (mean difference of −1.46, 95% −2.75 to −0.16, P = .03). Hyperglycemia was less frequent with high-dose nebulized budesonide (risk ratio, 0.13; 95% CI 0.03–0.46; P = .002).
CONCLUSIONS:
Based on our meta-analysis with a change in FEV1 as the primary end point, high-dose nebulized budesonide was an acceptable alternative to systemic corticosteroids in hospitalized subjects with COPD exacerbations who were not critically ill. Additional well-designed prospective studies are needed in both the acute care and ambulatory settings. We provide perspective on how this evidence might be applied in clinical practice.
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