Nebulized Corticosteroids in the Treatment of COPD Exacerbations: Systematic Review, Meta-Analysis, and Clinical Perspective.

Background: 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 FEV baseline versus the last measured value. Secondary outcomes were a change in (P ) and (P ) baselines versus the last measured values; FEV, P , and P 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 FEV between baseline and the last measured value (mean difference of 0.05, 95% CI -0.01 to 0.12, = .13) and P (mean difference of -1.14, 95% CI -2.56 to 0.27, = .11) but of inferior efficacy for P changes (mean difference of -1.46, 95% -2.75 to -0.16, = .03). Hyperglycemia was less frequent with high-dose nebulized budesonide (risk ratio, 0.13; 95% CI 0.03-0.46; = .002).

Conclusions: Based on our meta-analysis with a change in FEV 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.