Background: Corticosteroids in the setting of an acute exacerbation of improve COPD symptoms but do not affect the decline in lung function, rate of repeat exacerbations after a month, or mortality. There is concern regarding the cumulative adverse effects over time. Limited prior research suggests that a patient’s blood eosinophil count may be useful for determining the necessity of steroids for treatment of exacerbation.
Dr. Nicholas Dupuis
Study design: Randomized, controlled, open-label trial.
Setting: Respiratory departments of three university hospitals in Denmark.
Synopsis: A total of 318 patients admitted for COPD exacerbation were randomized to standard or eosinophilia-guided therapy. On day 1, all patients received 80 mg of IV methylprednisolone. The standard-therapy group then received 37.5 mg of oral prednisolone for 4 more days. In contrast, the eosinophilia-guided group received prednisolone only if their blood eosinophil count was 300 cells/mcL or greater.
The primary outcome of days alive and out of the hospital within 14 days after recruitment was similar between groups (9 days; P = .34), along with the secondary outcome of treatment failure (26%; P = .90). Importantly, the cumulative steroid dose in the eosinophilia-guided group was lower than that of the control group at days 5, 30, and 90 (P less than or equal to .0002). Additionally, the control arm had worsening of baseline diabetes within 30 days and was more likely to require antibiotics for infections within 90 days.
Although not statistically significant, a trend was noted toward increased readmission for COPD exacerbations or death at 30 days in the eosinophilia-guided group (25% vs. 17% of control; P = .10). Future work will need to further study this trend.
Bottom line: Eosinophilia-guided treatment of COPD exacerbations reduced the cumulative exposure of steroid therapy, thereby decreasing side effects, although further study of safety profile is warranted.
Citation: Sivapalan P et al. Eosinophil-guided corticosteroid therapy in patients admitted to hospital with COPD exacerbation (CORTICO-COP): A multicenter, randomized, controlled, open-label, non-inferiority trial. Lancet Respir Med. 2019 Aug;7(8): 699-709.
Dr. Dupuis is a hospitalist at Maine Medical Center in Portland.