Oral corticosteroid trials in the management of stable chronic obstructivepulmonary disease

Although recent guidelines for managing chronic obstructive pulmonary disea se (COPD) recommend a trial of oral corticosteroids in the initial assessme nt, its prognostic value remains unclear. We prospectively studied 127 adul ts (64% men) with stable COPD (FEV1/FVC <60%) over 1 year. At entry, we mea sured lung volumes, gas transfer factor, respiratory symptoms (by questionn aire), and peripheral blood eosinophil count. Skin-prick testing was done, and spirometry after nebulized 5 mg salbutamol and, after 2 weeks, oral pre dnisolone. Physician A gave all patients inhaled beclomethasone dipropionat e (800 mcg/day), whereas physician B prescribed this only to those with a p ositive oral corticosteroid trial. At 1 year, spirometry and respiratory qu estionnaire were repeated, with an estimate of overall symptom severity on a visual analogue scale. Followup 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 (2 3%) responded to corticosteroids and salbutamol. Patients in all groups wer e comparable, except that the prednisolone responders had a higher mean eos inophil count (p<0.001) and more were ex-smokers (p<0.001). Only the respon se to oral prednisolone correlated with the change in prebronchodilator FEV 1 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, corticosteroi d trials contribute information additional to that gained from nebulized br onchodilator reversibility testing. Patients with a positive response to a corticosteroid trial are more likely to have improved symptomatically and s pirometrically at 1 year.