Blood eosinophils can guide steroid treatment in COPD: study


By Selina Wellbelove

14 Nov 2023

Dr Sanjay Ramakrishnan

Blood eosinophils can be used as a biomarker in primary care to guide the use of systemic corticosteroids in patients with an acute COPD exacerbation, research confirms.

A randomised, placebo-controlled trial carried out at 14 primary-care centres in the UK showed that blood eosinophil-guided treatment with prednisolone at the time of acute COPD exacerbation was non-inferior to standard care and “can be used to safely reduce systemic glucocorticoid use in clinical practice”, according to the paper published in The Lancet Respiratory Medicine.

In the trial, 93 participants (mean age 70 years, mean per cent predicted FEV1 60.9%) were randomly assigned to receive blood eosinophil-directed treatment (BET; oral prednisolone 30mg once daily if eosinophil count was high [≥2%] or placebo if eosinophil count was low [<2%]) or standard care treatment (ST; prednisolone 30 mg once daily irrespective of the eosinophil test result).

The primary outcome was the rate of treatment failure, defined by the research team as “any need for re-treatment with antibiotics or steroids, hospitalisation for any cause, or death, assessed at 30 days after exacerbation”.

Results showed that the blood eosinophil treatment group had 40% fewer treatment failures than the standard care arm (14/73 vs 23/71, respectively).

Also, analysis revealed that in participants who took prednisolone for 14 days systemic glucocorticoids were harmful for those who had a low (<2%) blood eosinophils count.

“Our results showed that blood-eosinophil guided therapy was non-inferior to standard care with a lower cumulative oral prednisolone dose; with no clinical or statistically significant difference in lung function, symptom, or quality of life recovery, despite 30% of participants being treated with placebo for their exacerbation,” said the research team led by Dr Sanjay Ramakrishnan, an Australian respiratory physician now working at the University of Oxford.

“Biomarker-based subgroup analysis also showed that the greatest benefit in lung function and COPD specific quality life was in participants with a high eosinophil count receiving prednisolone,” the authors said.

As such, “health systems need to encourage systematic assessment of COPD exacerbations to provide patients with the right therapy in a precision biomarker-directed way”.

The findings could “radically improve clinical practice”, particularly as the study was carried out in the primary care setting where most patients experiencing COPD exacerbations seek care, noted US pulmonologists Dr Alejandro Comellas and Spyridon Fortis, University of Iowa Hospitals, in a linked comment.

The study suggests that “blood eosinophil counts should be considered as a component of point-of-care testing to guide systemic glucocorticoids in acute COPD exacerbation,” and that “patients with low eosinophil counts should avoid unnecessary and potentially harmful treatment with systemic glucocorticoids”, they added.

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