steroid trial in COPD

Last reviewed 02/2021

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)
  • the FEV1 threshold has been increased from that previously recommended in the 1997 BTS COPD Guideline, which stated that an FEV1 increase >200ml and 15% of the baseline value showed reversibility
    • threshold was increased to overcome the large variability in FEV1 response that is seen from day to day - however, looking for such large changes in FEV1 may not identify people with a dual diagnosis of asthma and COPD
  • note that the 2005 British Asthma Guidelines produced by the BTS and the Scottish Intercollegiate Guidelines Network (SIGN) advocates an increase of >200ml in FEV1 and 15% of the baseline value as one of the objective methods to diagnose asthma - however, these guidelines do not deal specifically with the differentiation of asthma from COPD

Reference:

1. NICE (February 2004). Chronic obstructive pulmonary disease - management of chronic obstructive pulmonary disease in adults in primary and secondary care.
2. Walters J et al. Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005;(3):CD005374.
3. MeReC Briefing 2006; 33:1-8.