Per Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD) updated in 2023, oral glucocorticoids are considered equally effective as intravenous (IV) administration. Studies, mostly set in hospitals, suggest systemic glucocorticoids in COPD exacerbations can shorten recovery time, improve lung function and oxygenation, reduce the risk of early relapse and treatment failure, and decrease hospital length of stay. The recommended systemic corticosteroid dose is 40 mg of prednisone-equivalent daily for 5 days. Longer courses of oral corticosteroids were associated with an increased risk of pneumonia and mortality in one observational study. Even short courses of corticosteroids were associated with an increased risk of pneumonia, sepsis, and death. If a steroid-sparing regimen is needed, one study found nebulized budesonide alone provides similar benefits to IV methylprednisolone. The only time systemic dexamethasone, specifically, is mentioned in these updated guidelines is in the context of hospitalized patients with COVID-19. [1]
In addition to two relevant randomized trials (Tables 1 and 2), a 2021 prospective study, published as a poster abstract, investigated the use of IV dexamethasone for hyperinflammatory cardiopulmonary exacerbations in very elderly patients with acute heart failure and concomitant acute lung diseases characterized by inflammation. The study enrolled 157 patients aged ≥80 years with acute heart failure and symptoms attributable to acute bronchitis, pneumonia, or exacerbated COPD. Patients also had N-terminal pro b-type natriuretic peptide (NT-proBNP) levels ≥ 3,000 pg/mL and radiographic evidence of pulmonary congestion with or without lung consolidation; patients with COVID-19 were excluded from the study. A total of 96 patients with C-reactive protein (CRP) values > 20 mg/dL were randomized into two groups: 48 patients were treated with open-label IV dexamethasone 8 mg/day in addition to usual therapies, and 48 received usual therapy alone. Patients were assessed for clinical recovery time, duration of hospitalization, in-hospital mortality, need for re-hospitalization, and mortality at one month. The dexamethasone group showed faster clinical recovery and shorter hospital stays, but no significant differences were seen for in-hospital mortality, 30-day mortality, or re-hospitalization rates compared to the usual therapy group. Although this study suggests a favorable response to dexamethasone in terms of clinical recovery and hospitalization length, the authors note that further evaluation through larger double-blind randomized trials is necessary to assess dexamethasone’s potential impact on mortality improvement. [2]