Eosinophil-guided therapy reduces steroids in COPD exacerbations

Blood eosinophil counts could be used to guide reductions in systemic corticosteroid dosing in patients with acute exacerbations of COPD without compromising outcomes, a Danish study has shown.

A randomised, open-label trial in 358 patients hospitalised with acute exacerbations showed that use of eosinophil-guided corticosteroid therapy reduced steroid duration from five days to two days and was non-inferior to standard therapy in terms of short term COPD outcomes.

In the study, patients over 40 presenting with moderate COPD exacerbations were given 80mg of IV methylprednisolone on day 1 then assigned to either standard therapy with 37·5mg oral prednisolone oral daily on days 2 to 5, or eosinophil-guided treatment in which prednisolone was only given when blood eosinophil counts were higher than 300 cells/uL.

Eosinophil-guided therapy did not result in a difference in the primary endpoint of days alive and out of the hospital within 14 days after recruitment compared with standard therapy (mean 8·9 vs 9·3 days, p=0·34) or in the risk of treatment failure at 30 days (26% in both groups).

However, eosinophil-guided therapy was associated with a reduction in the duration (two vs five days) and total dose (121mg vs 225mg)  of systemic corticosteroid administered compared with standard therapy.

Presenting their findings at ATS 2019, the authors suggested it might be safe to use an algorithm based on peripheral blood eosinophil counts to select patients with exacerbations who would benefit the most from systemic steroids, and to minimise harm to non-responders.

“Implementation of a strategy of biomarker-guided corticosteroid therapy would most likely reduce, both on individual and societal levels, the burden of corticosteroid adverse effects substantially in a large and vulnerable patient group, they said.

“Additionally, since the differential count of white blood cells is inexpensive and readily available in most hospital settings, this strategy can easily be implemented, without establishing new hospital infrastructure, even in resource-constrained environments.

An accompanying commentary published in Lancet Respiratory Medicine noted that many patients with COPD exacerbations still receive prolonged courses of high-dose steroids that have numerous adverse effects. This was despite evidence that exacerbations are biologically heterogeneous and that a subset of patients with low eosinophils might derive no respiratory benefit, and perhaps be harmed, from systemic corticosteroids

“Although [the] study does not answer all the questions about the predictive role of blood eosinophils in acute COPD exacerbations, and perhaps an eosinophil-guided approach is not yet ready for routine clinical use, it is clearly a step in the right direction and points towards a precision approach to a problem we currently treat near uniformly,” it concluded.

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