Q J Med 1999; 92: 395-400
© 1999 Association of Physicians
Oral corticosteroid trials in the management of stable chronic obstructive pulmonary disease
From the Aintree Chest Centre, University Hospital Aintree and University Department of Medicine, Liverpool, UK
Received 17 November 1998 and in revised form 5 May 1999
Address correspondence to Professor P.M.A. Calverley, Aintree Chest Centre, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL
Although recent guidelines for managing chronic obstructive pulmonary disease (COPD) recommend a trial of oral corticosteroids in the initial assessment, its prognostic value remains unclear. We prospectively studied 127 adults (64% men) with stable COPD (FEV1/FVC <60%) over 1 year. At entry, we measured lung volumes, gas transfer factor, respiratory symptoms (by questionnaire), and peripheral blood eosinophil count. Skin-prick testing was done, and spirometry after nebulized 5 mg salbutamol and, after 2 weeks, oral prednisolone. Physician A gave all patients inhaled beclomethasone dipropionate (800 mcg/day), whereas physician B prescribed this only to those with a positive oral corticosteroid trial. At 1 year, spirometry and respiratory questionnaire were repeated, with an estimate of overall symptom severity on a visual analogue scale. Follow-up data were available in 104 (82%) patients. Of these, 32 (31%) were unresponsive to salbutamol and prednisolone; 48 (46%) were responsive to beta agonists but not to corticosteroids, and 24 (23%) responded to corticosteroids and salbutamol. Patients in all groups were comparable, except that the prednisolone responders had a higher mean eosinophil count (p<0.001) and more were ex-smokers (p<0.001). Only the response to oral prednisolone correlated with the change in pre-bronchodilator FEV1 over 1 year. Oral prednisolone responders had higher FEV1 at 1 year (p<0.02) and significantly lower symptom scores (p<0.02). In COPD, corticosteroid trials contribute information additional to that gained from nebulized bronchodilator reversibility testing. Patients with a positive response to a corticosteroid trial are more likely to have improved symptomatically and spirometrically at 1 year.
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