Consider Eosinophil Counts When Initiating Inhaled Steroids for COPD

You’ll hear more emphasis on limiting inhaled corticosteroids for COPD...due to updated guidelines.

TV ads push steroid combo inhalers (Breo, etc) for COPD. And now we have lower-cost generics for Advair (salmeterol/fluticasone).

But inhaled steroids don’t benefit all patients with COPD...and are linked to pneumonia and thrush.

New guidelines suggest considering the blood eosinophil count to help determine if starting an inhaled steroid may be beneficial.

The idea is eosinophils can help pinpoint COPD patients who have inflammation...and may be more likely to benefit from inhaled steroids.

Evidence suggests inhaled steroids may decrease COPD exacerbations if eosinophils are above 300 cells/µL...or about 4% of the total white count. But there may not be benefit below 100 cells/µL...or less than 2%.

Be aware, these are “soft” cutoffs.

Plus steroids drop eosinophils, so counts may be low in patients who recently used an inhaled or systemic steroid...and won’t help decide about stopping an inhaled steroid.

Continue to save inhaled steroids for COPD patients with severe symptoms or exacerbations. If you’re on the fence about starting one, consider the eosinophil count to help decide.

But first optimize bronchodilators and reinforce proper inhaler use.

Start with a long-acting muscarinic antagonist (Spiriva, etc) OR a long-acting beta-agonist (Serevent, etc)...plus a short-acting bronchodilator (albuterol, etc) PRN to relieve symptoms.

For persistent or more severe symptoms, combine a long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist (LABA)...before going to a steroid, especially if eosinophil counts are low.

Expect to see more of these “LABA/LAMA” combo inhalers. Duaklir (formoterol/aclidinium) is now the fifth option...all are effective. Combos cost at least $370/month...generally less than 2 separate inhalers.

Find tips to educate patients in our toolbox, Improving COPD Care...and use our chart, Inhaled Meds for COPD, to sort through options.

Key References
  • https://goldcopd.org/wp-content/uploads/2019/11/GOLD-2020-REPORT-ver1.0wms.pdf (12-16-19)
  • Lancet Respir Med 2019;7(9):745-56
  • Lancet Respir Med 2018;6(2):117-26 4
  • Medication pricing by Elsevier, accessed Dec 2019
Prescriber's Letter. January 2020, No. 360116


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