5 Days vs 14 Days of Steroids for COPD Exacerbations: The REDUCE Trial

Currently, guidelines advocate for systemic steroid therapy in the management of acute exacerbations of COPD. Multiple randomized clinical trials have shown the benefits on clinical outcomes of COPD (Reduction of LOS and quicker recovery of FEV1). The optimal dose and duration for COPD is not really known. Furthermore, long-term use of glucocorticoids can cause osteoporosis, diabetes mellitus, and most importantly is a risk factor for increased mortality in COPD.

What is the REDUCE Trial?

REDuction in the Use of Corticosteroids in Exacerbated COPD

What they did:

Randomized Placebo Controlled, Double Blind, Non-Inferiority Multicenter Trial
5 Swiss Teaching Hospitals
314 patients with COPD
Treatment with 40mg of prednisone daily for 5 days versus 14 days

Primary Outcome:

Time to next exacerbation within 180 days

Results:

Exacerbation rate 35.9% (short term treatment) vs 36.8% (conventional treatment)
Median time to exacerbation 43.5 days (short term treatment) vs 29 days (conventional treatment)
No difference in mortality
No increase in need for mechanical ventilation between treatment regimens
Hypertension developed or worsened in 11.6% (short term treatment) vs 17.8% (conventional treatment)
No difference in hyperglycemia in the two groups

Limitations:

All patients, regardless of GOLD classification were treated with inhaled long-acting Beta-agonists, glucocorticoids, and tiotropium
All patients received antibiotic treatment regardless of sputum production or procalcitonin level
Most of the patients in this study had severe or very severe COPD

Conclusion:

5-day treatment with systemic glucocorticoids is non-inferior to 14 day treatment and significantly reduces glucocorticoid exposure

In my opinion, how will this affect your practice?

Patients in this study were over-treated with antibiotics, which is not the standard of care for hospitalized patients.
A 5-day treatment regimen is non-inferior to a 14 day regimen of glucocorticoids
It may be reasonable to treat patients with 5 days of glucocorticoids for COPD exacerbations

References:

Leuppi JD et al. Short-Term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: The REDUCE Randomized Clinical Trial. JAMA 2013; 309 (21): 1 – 9. PMID: 23695200

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Dr. Salim R. Rezaie is a physician at the University of Texas Health Science Center at San Antonio. He is double board-certified in Emergency Medicine and Internal Medicine.