Does magnesium improve outcomes in COPD exacerbations?

February 4, 2026

February 4, 2026

Ahmed Awaad, Specialty Doctor in Emergency Medicine (Northampton General Hospital)

In [patients presenting with an acute exacerbation of COPD] does [intravenous magnesium sulphate as an adjunct to standard therapy] improve [clinical outcomes such as dyspnoea, lung function, oxygenation, need for hospitalisation, or mortality]

A 72‑year‑old with known COPD (FEV₁ 45% predicted) presents to ED with three days of worsening dyspnoea and productive cough. After oxygen titrated to target saturations, back‑to‑back salbutamol/ipratropium nebulisers, and oral prednisolone, he remains breathless with SpO₂ 90–91% on 2 L/min. You consider IV magnesium sulfate (2 g) as an adjunct, recalling its bronchodilatory role in severe asthma, and wonder whether the evidence supports improved outcomes in AECOPD.

A PubMed‑only search was performed using MeSH and free‑text terms relating to COPD, acute exacerbations, and intravenous magnesium sulphate. The search was restricted to studies published between 2006 and 2026, consistent with the publication timeline displayed in PubMed. All retrieved records were exported and screened by title, abstract, and full text. Reference lists of included studies were also reviewed to identify any additional eligible trials or reviews.
Search terms used:
("Chronic Obstructive Pulmonary Disease"[Mesh]
OR COPD[tiab]
OR "acute exacerbation"[tiab]
OR AECOPD[tiab])
AND
("Magnesium Sulfate"[Mesh]
OR "magnesium sulfate"[tiab]
OR "magnesium sulphate"[tiab]
OR magnesium[tiab])
AND
(intravenous[tiab]
OR infusion[tiab]
OR IV[tiab])

Filters applied: Humans, Adults, English, 2006–2026, Clinical Trials, RCTs, Systematic Reviews, Meta‑analyses

20 articles found between 2006–2026

Excluded at title/abstract level (n = 10):

Not COPD‑related (e.g., asthma‑only trials) (n = 4)
Magnesium used in non‑respiratory conditions (e.g., trigeminal neuralgia, patents, asthma physiology) (n = 3)
Studies of stable COPD, not acute exacerbation (n = 2)
Nebulised magnesium only (without IV arm) (n = 1)

Full‑Text Review of the 10 full texts:
Excluded (n = 4):

No intravenous magnesium intervention (e.g., nebulised‑only studies) (n = 2)
Stable COPD interventions, not AECOPD (n = 1)
Non‑comparative design or unclear outcome data (n = 1)

Using the PubMed “similar articles” and backward reference tracking from the Cochrane Review:
Added 2

Cochrane Review (2022) on magnesium in AECOPD (comprehensive synthesis of 11 RCTs) [ebm.bmj.com]
Shivanthan 2014 systematic review of magnesium for COPD exacerbation (PubMed #13)

Final included studies:
8 studies total, consisting of:
Randomised Controlled Trials (IV magnesium for AECOPD):

Jahanian 2021 – IV magnesium in ED AECOPD patients [bestbets.org]
Vafadar Moradi 2021 – Adjunctive IV magnesium trial (Acad Emerg Med)
Mukerji 2015 – Parallel‑group RCT of IV magnesium in AECOPD
Abreu González 2006 – IV magnesium in COPD exacerbations (Spanish trial)

Systematic Reviews / Meta‑analyses:

Cochrane Review 2022 – 11 RCTs on magnesium for AECOPD [ebm.bmj.com]
Farid 2025 – IV magnesium systematic review & meta‑analysis [bestpractice.bmj.com]
Jahangir 2022 – Systematic review & meta‑analysis of magnesium in COPD
Shivanthan 2014 – Systematic review of randomised trials for magnesium in COPD exacerbation

A total of 8 studies were ultimately included in this BET:

4 Randomised Controlled Trials (including Jahanian 2021, Vafadar Moradi 2021, Mukerji 2015, Abreu González 2006) [bestbets.org]
4 Systematic Reviews / Meta‑Analyses (including Cochrane 2022, Farid 2025, Jahangir 2022, Shivanthan 2014) [ebm.bmj.com] [bestpractice.bmj.com]

Intravenous magnesium sulphate has long been recognised for its bronchodilatory effects in acute severe asthma due to its smooth‑muscle relaxation, calcium‑antagonist properties, and possible anti‑inflammatory actions. It is therefore biologically plausible that it may offer similar benefit in acute exacerbations of COPD (AECOPD), particularly in patients with bronchospastic physiology. However, the evidence base for COPD is considerably smaller, more heterogeneous, and less consistently positive than the equivalent asthma literature.
The trials identified in this review vary widely in size, methodology, intervention timing, and outcome measurement. The best available evidence suggests that IV magnesium improves short‑term physiological parameters, especially FEV₁, oxygen saturation, and subjective dyspnoea. This is most robustly demonstrated in the Jahanian et al. 2021 RCT, where FEV₁ and SpO₂ improved significantly within both 45 minutes and 6 hours after administration, accompanied by clinically meaningful reductions in respiratory rate and Borg dyspnoea scores. Similar, though sometimes less pronounced, improvements are noted in older RCTs such as Abreu González 2006 and the New Zealand Mukerji 2015 pilot trial, where improvements in flow parameters (FVC/FEV₁) were also observed. [bestbets.org]
The Cochrane Review (2022) provides the strongest synthesis of randomised evidence. It concludes that intravenous magnesium may reduce hospital admissions, may shorten length of stay, and has consistent—though modest—effects on dyspnoea relief. However, the review emphasises the limited certainty of evidence, owing to small sample sizes, methodological variation, and often poor reporting in individual trials. [ebm.bmj.com]
The Farid et al. (2025) systematic review adds a contemporary perspective by pooling seven RCTs with two observational cohorts, concluding that IV magnesium offers an “effective adjunct therapy” with improvements across multiple clinical parameters. Yet the meta‑analysis is constrained by the heterogeneity of included studies, particularly in dosing regimens, outcome time-frames, and inclusion criteria. [bestpractice.bmj.com]
A notable gap in the literature is the lack of high‑quality, adequately powered ED‑based RCTs studying magnesium’s impact on more meaningful clinical endpoints such as need for hospitalization, need for non‑invasive ventilation, treatment failure, or mortality. Most trials are small (often <70 participants), single‑centre, and focus heavily on short‑term physiological measures, which may not reliably predict medium‑ or long‑term outcomes in COPD.
The Vafadar Moradi (2021) trial supports clinical improvement but is limited by missing abstracted data, restricting full appraisal, while other studies—such as the Spanish trial from 2006—are older and reflect practice patterns that may not fully align with modern COPD management. There is also considerable inconsistency in patient populations between studies, with some including hospitalised rather than ED patients, and others enrolling patients who may resemble asthmatic physiology more than classical COPD.
Despite these limitations, the direction of effect is consistently favourable, with no major safety concerns reported across any of the intravenous trials. Magnesium sulfate is inexpensive, easy to administer, and familiar to emergency clinicians. Given its physiological rationale and positive—if modest—effects in the existing evidence base, IV magnesium appears to be a reasonable adjunct treatment for moderate–severe AECOPD when standard ED therapy has not produced sufficient clinical improvement. Its role is unlikely to be transformative, but it may provide incremental benefit in selected patients.
Future research should aim to determine:

which AECOPD phenotypes benefit most (e.g., bronchospastic vs hypercapnic vs inflammatory),
the optimal dose and timing of IV magnesium,
and whether short‑term physiological improvements reliably translate into reductions in hospital admission, need for NIV, or length of stay.

At present, magnesium remains a promising but incompletely validated adjunct in COPD exacerbations—beneficial for symptom and physiological improvement, safe, inexpensive, and reasonable to consider after first‑line therapies, but not yet supported by large‑scale trial evidence for more definitive outcomes.

Intravenous magnesium sulfate appears to improve short‑term physiological outcomes in acute COPD exacerbations and may reduce hospitalizations or LOS. Evidence is supportive but heterogeneous. It is reasonable to consider IV magnesium as an adjunct when initial bronchodilators and corticosteroids provide insufficient improvement.

Level 2: Studies considered were neither 1 or 3

1. Ni H, Aye SZ, Naing C.. Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease.
2. Vafadar Moradi E, Pishbin E, Habibzadeh SR, Talebi Doluee M, Soltanifar A.. The Adjunctive Effect of Intravenous Magnesium Sulfate in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.
3. Jahanian F, Khatir IG, Ahidashti HA, Amirifard S.. The Effect of Intravenous Magnesium Sulphate as an Adjuvant in the Treatment of Acute Exacerbations of COPD in the Emergency Department.
4. Farid T, Omar AS, Kandi SV, et al.. Intravenous Magnesium Sulphate as an Adjuvant Therapy for Acute Exacerbations of COPD: A Systematic Review and Meta‑analysis.
5. Mukerji S, Shahpuri B, Clayton‑Smith B, et al.. Intravenous magnesium sulphate as an adjuvant therapy in acute exacerbations of COPD: a pilot randomised controlled trial.
6. Abreu González J, Hernández García C, Abreu González P, et al.. Effect of intravenous magnesium sulfate on COPD exacerbations requiring hospitalisation: a randomised placebo‑controlled trial.
7. Shivanthan MC, Rajapakse S.. Magnesium for acute exacerbation of chronic obstructive pulmonary disease: A systematic review of randomised trials.
8. Jahangir A, Zia Z, Niazi MRK, et al.. Efficacy of magnesium sulfate in the chronic obstructive pulmonary disease population: a systematic review and meta-analysis.