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Case Spotlight

Pulmonology

General

Summary

  • 72 year old male with CAD, DM, COPD/Asthma with worsening COPD symptoms.
  • PCP wants advice on managing this patient’s COPD exacerbation and whether the patient should be started on chronic prednisone.
  • Specialist relayed that most COPD patients do not benefit from chronic prednisone, but that those with a more-asthma like phenotype may, and questioned whether this patient could be one of them. If so, the specialist said add-on therapy with one of the new asthma biologics might benefit the patient and would recommend that he be seen by a pulmonologist when possible.
  • Specialist also suggested that chronic low-dose azithromycin could be a good option for the interim.

eConsult transcript

PCP submission:

72 year old male with CAD, DM, COPD/Asthma with worsening COPD symptoms.

He has had 4 exacerbations requiring prednisone bursts or tapers from various providers in the past 3 months. When he completes taper, typically feels worse after about 2 days. At prior baseline had 1 block exercise tolerance and now gets breathless with walking around the house with a walker.

I feel that I might have reached max medical management within primary care. I think his cardiac disease is stable, but COPD may be progressing to the point of needing chronic prednisone.

Would you start this patient on chronic prednisone, and at what dose? Any other medications to try?

Specialist response:

  1. If a patient like this presented to me, these would be my general thoughts. Thank you for reaching out to me. 
  2. The vast majority of COPD patients do not benefit from chronic prednisone and therefore only suffer from side effects without benefit. Many patients feel worse when they come off prednisone, but often that is just due to losing the general euphoric effect that they confuse with worsening dyspnea. In patients like this, I check spirometry when they complain of being worse off prednisone and usually am able to show them that they are NOT worse. 
  3. That being said, there are rare patients who do benefit, those with a more asthma-like phenotype. Given that he quit smoking in the 1970s, I wonder if he might fall into that category. Did he have childhood asthma, or does he have environmental allergies that would increase the likelihood of asthma? Does he have >300 eosinophils in his CBC when off steroids? Is his IgE elevated? Any of these would suggest that add-on therapy with one of the new asthma biologics might be of benefit, and I would therefore recommend that he be seen by a pulmonologist when possible. 
  4. In the meantime, chronic low-dose azithromycin has been shown to decrease the frequency of COPD exacerbations and is a good option here. 500 mg TIW, and if there are side effects, can use 250 TIW. Make sure that his previous ECG does not show prolonged QTc. If all else fails and you can’t get him to a pulmonologist any time soon, would use no more than 5 mg a day of prednisone, and make it clear that it is temporary until a better solution can be found. Good luck.

Tags: COPD, exacerbation, chronic illness, chronic prednisone