Steroid trial in COPD

Steroid trial:

e.g. 30 mg prednisolone orally for two weeks only and test reversibility, OR, a six week course of inhaled corticosteroid (beclomethasone 500 mcg bd or equivalent).

A substantial response (>400ml) may indicate asthma (1).

NICE suggests that routine reversibility testing is now unnecessary in patients with a convincing history and examination compatible with COPD, and it may even be misleading

• this is because repeated spirometry can show small spontaneous fluctuations leading to inconsistency i.e. nonreproducibility
• the response to long-term therapy is not helpfully predicted by acute reversibility testing
• asthma and COPD can usually be distinguished on the basis of history and examination. In certain circumstances, where diagnostic doubt remains, or where the patient is thought to have both COPD and asthma, reversibility testing or serial PEF rate measurements should be carried out
  • asthma is suggested if there is
    • a large (>400ml) FEV1 response to bronchodilators
    • a large (>400ml) FEV1 response to 30mg oral prednisolone daily for two weeks
    • serial PEFR measurements showing 20% or greater diurnal or day-to-day variability

Notes:

• there is no evidence to support the long-term use of oral steroids at doses less than 10-15 mg. Potentially harmful adverse effects e.g. diabetes, hypertension, osteoporosis would prevent recommending long-term use at these high doses in most patients (2)
• with respect to reversibility testing (3)
  • according to the 2019 British Asthma Guidelines by the BTS and SIGN:
    • In adults with obstructive spirometry, an improvement in FEV1 of 12% or more in response to either beta- agonists or corticosteroid treatment trials, together with an increase in volume of 200 ml or more, is regarded as a positive test, although some people with COPD can have significant reversibility.
    • An improvement of greater than 400 ml in FEV1 strongly suggests underlying asthma. In children, an improvement in FEV1 of 12% or more is regarded as a positive test.

Reference:

• 1. National Institute for Health and Clinical Excellence (NICE) 2018. Chronic obstructive pulmonary disease in over 16s: diagnosis and management
• 2. Mandru R, Zhou CY, Pauley R, Burkes RM. Considerations for and Mechanisms of Adjunct Therapy in COPD. J Clin Med. 2021 Mar 16;10(6):1225. doi: 10.3390/jcm10061225.
• 3. British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) 2019. British Guideline on the Management of Asthma. A national clinical guideline