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 (LOS). 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 that 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 (HF) and concomitant acute lung diseases characterized by inflammation. The study enrolled 157 patients aged ≥80 years with acute HF 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]
A 2021 single-blind, randomized clinical trial evaluated the comparative efficacy of IV dexamethasone (8 mg daily) and hydrocortisone (200 mg daily in divided doses) in the management of COPD exacerbations. The trial enrolled 70 patients aged over 40 with confirmed COPD, randomly assigned into two treatment groups. The interventions were assessed on their impact on clinical symptoms, including shortness of breath, sputum volume and viscosity, cough, oxygen saturation, peak expiratory flow (PEF), and biomarkers of inflammation and oxidative stress such as C-reactive protein (CRP) and malondialdehyde (MDA). Outcomes were measured at baseline, day two, and discharge, and side effects, such as edema and blood pressure changes, were monitored systematically. Both dexamethasone and hydrocortisone demonstrated equivalent improvements in clinical indicators, with significant symptom alleviation observed within each group (p<0.001). However, intergroup analyses revealed statistically significant differences on the first day for shortness of breath, sputum volume, and arterial oxygen saturation (p= 0.02, p= 0.01, p= 0.02, respectively). These differences equalized by discharge, suggesting comparable long-term efficacy. Inflammatory markers, including CRP and WBC counts and MDA levels, showed significant reductions in both cohorts without meaningful differences between the groups. Notably, hydrocortisone was associated with a higher incidence of edema (17% vs. 5.7%, p= 0.009), likely attributable to its mineralocorticoid activity. These findings underscore the therapeutic equivalence of dexamethasone and hydrocortisone in COPD exacerbations, with dexamethasone offering a potential advantage for patients susceptible to fluid retention. [3]
A 2023 retrospective, cross-sectional, comparative study evaluated the effects of pre-hospital dexamethasone administration on outcomes in patients experiencing exacerbations of asthma and COPD. The analysis utilized emergency medical service (EMS) patient care reports and emergency department (ED) records from January 2021 to October 2022, focusing on 200 patients (93 with COPD and 107 with asthma) who were either treated or not treated with dexamethasone in the pre-hospital setting. Key parameters examined included ED-LOS and hospital admission rates. Patients in the dexamethasone-treated group received 8 mg intravenously administered by paramedics or emergency nurse practitioners at the scene, based on nationally established EMS protocols. The findings demonstrated that pre-hospital dexamethasone administration was associated with a significant reduction in ED-LOS among asthma exacerbation cases, with median times of 235 minutes versus 322 minutes when compared to the untreated group (p= 0.003). However, while hospital admission rates for asthma patients trended lower in the dexamethasone-treated group (60.4% vs. 78.0%), the difference was not statistically significant (p= 0.510). Among COPD patients, dexamethasone use was associated with a non-significant reduction in ED-LOS (232 vs. 296 minutes, p= 0.106) and hospital admission rates (80.8% vs. 85.4%, p= 0.561). These results emphasize the potential benefits of pre-hospital dexamethasone in reducing ED-LOS in asthma exacerbations, though its impact on hospital admission rates and outcomes in COPD remains less definitive. [4]