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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 optionwhen systemic corticosteroids are not available, and/or the use of steroids is contraindicated because of a severe or life-threatening condition or impairment that causes an increase in systemic corticosteroid levels. The rationale is that inhaled corticosteroids can enhance systemic corticosterogenesis and therefore improve disease outcomes, although it is considered more prudent to maintain systemic levels of corticosteroids to maintain an optimal response to corticosteroids. Corticosteroids can also be administered directly as inhaled drugs. An overview of the rationale for this approach in COPD is presented below, beginning with the more general principle in order to provide an overview of important aspects. For additional information on corticosteroids, including how these are selected, dose requirements, side effects, and more, read the COPD guideline. General Principles for the Management of COPD Use of steroids to manage the exacerbation of COPD is preferred. However, systemic corticosteroids are useful when not available or when systemic corticosteroids are contraindicated. In moderate to severe COPD, patients may need systemic corticosteroids to maintain an initial response. If corticosteroids are given early for relief of symptoms, patients who are otherwise not at risk for worsening of their condition will continue to respond well to treatment in the absence of increased systemic corticosteroid levels. The benefits of systemic and inhaled administration outweigh the potential risks associated with these route of steroids administration; these considerations, however, do not ensure compliance with the guidelines for this approach. Use of systemic steroids to increase steroid levels is recommended with careful consideration to the specific indications for using them. Because they are the most effective at rapidly treating patients with severe bronchiolitis or emphysema, systemic corticosteroids are considered as a second-line therapy for patients who are not on treatment of systemic steroids for treatment of COPD. Patients in the third group (those with severe exacerbations) may benefit from inhaled corticosteroids to reduce or prevent exacerbations from exacerbations of COPD. Corticosteroids that are given by inhalation are generally preferred over systemic steroids. These are the most commonly used steroids for pulmonary exacerbations and are also recommended. However, there are a variety of considerations for whether this is an appropriate option. Because most patients with COPD also suffer from asthma (mostly bronchiolitis or emphysema), it should be used judiciously to determine Related Article: