Steroids can be stopped in COPD if blood eosinophil count is low


By Emma Wilkinson

12 May 2020

Patients with COPD who are not having frequent exacerbations can safely be taken off inhaled corticosteroids (ICS) as long as their blood eosinophil count is less than 300 μL−1, new guidance from the European Respiratory Society recommends.

Those patients who are advised to stop ICS treatment should instead be treated with one or two long-acting bronchodilators, the ERS advises.

It is hoped the clear recommendations will reduce the number of patients with COPD prescribed ICS when they are not indicated.

Speaking with the limbic, guideline author Professor James Chalmers from the University of Dundee, Scotland, said the evidence was clear that ICS only work in a small proportion of patients with COPD and their disease would be better controlled with bronchodilators.

His research has shown that even with improvements over time in the proportion of COPD patients, inappropriately prescribed ICS is still too high at around 50%.

“We need a solution that can safely identify patients who can stop their steroid and go onto a more effective regimen without taking ICS away from the 20% of patients who do well with a steroid,” he said.

The guideline committee identified four randomised controlled trials looking at clinical outcomes of stopping steroid use over at least six months.

They concluded that although the evidence is limited due to the small number of studies that met their criteria.

“Inhaled corticosteroid withdrawal does not increase exacerbation frequency or result in clinically important changes in symptoms or lung function,” the recommendations conclude.

Professor Chalmers who is also a Consultant Respiratory Physician said the evidence was clear that a cut off blood eosinophil count of 300 μL−1 taken together with a history of exacerbations could guide treatment decisions.

“Below 300 you could safely stop the drug and nothing happened. Above 300 the rates of exacerbations went up dramatically so it was absolutely clear you didn’t want to stop ICS in those patients.”

The clarity of the guidelines would help improve use of ICS and would be particularly helpful in primary care when a lot of the prescribing decisions were made he added.

“We know there’s a lot of anxiety about stopping steroids but that is mostly down to a misunderstanding of the disease. People have the impression if they’re going to stop them the patient will get dramatically worse. We shouldn’t have any fear about stopping them if we choose the right patients.”

He recommended reviewing patients during their routine check ups and taking into account history of exacerbation and blood eosinophil count.

“This is something I would do at the annual review.”

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