STARR2: A new approach for treating COPD exacerbations 

A point-of-care, eosinophil-guided prescription of prednisolone was non-inferior to standard-of-care prescription of prednisolone in the treatment of COPD exacerbations, the multicentre, randomised STARR2 trial showed. Personalised, endotype-based prednisolone treatment is possible for patients with COPD and should be implemented in the clinical guidelines, argued the research team.

“Corticosteroids are known to increase harm in our patients,” said Prof. Mona Bafadhel (King’s College London, UK) [1]. Evidence suggests that eosinophil-directed oral corticosteroid (OCS) treatment is non-inferior to standard-of-care OCS [2,3]. The multicentre, double-blind, randomised, placebo-controlled STARR2 trial (NCT04458636) aimed to confirm these results [1]. Patients with COPD (n=203) were randomised to standard-of-care OCS or blood-eosinophil-directed OCS in the treatment of exacerbations. In the experimental condition, participants received a placebo if their eosinophil count was <2% and prednisolone if eosinophil count was ≥2%. The primary outcome was treatment failure at day 30.

In the intention-to-treat analysis, eosinophil-directed care was non-inferior to standard-of-care (RR 0.82; 95% CI 0.54–1.23; P=0.34), with 27% and 34% of failed treatments in the experimental arm and the control arm, respectively. The per-protocol analysis confirmed the non-inferiority of the experimental treatment compared with the control arm in terms of treatment failure (19% vs 32%; RR 0.60; 95% CI 0.33–1.04; P=0.07). In addition, forced expiratory volume in 1 second (FEV₁) results, COPD Assessment Test (CAT) scores, and Visual Analogue Score (VAS) symptom scores did not display significant differences between the 2 treatment arms.

This large, primary care, COPD study showed that point-of-care eosinophil-guided prescription of OCS is safe and not associated with worse outcomes than standard-of-care prescription of OCS, concluded Prof. Bafadhel. “This new approach should be implemented in the guidelines, because it offers a more precise treatment and may reduce harmful events in our patients.”

1. Bafadhel M, et al. Point of care blood eosinophil guided oral prednisolone for COPD exacerbations: a multi-centre double blind randomised controlled trial (The STARR2 trial). ALERT 1, RCT711, ERS International Congress 2022, Barcelona, Spain, 4–6 September.
2. Bafadhel, M, et al. Am J Respir Crit Care Med. 2012;186(1):48–55.
3. Sivapalan P, et al. BMJ Open Respir Res. 2019;6(1):e000407.

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Posted on 30 October 202216 November 2022