STARR2: A new approach for treating COPD exacerbations

Point-of-care eosinophil-guided prednisolone was non-inferior to its standard-of-care prescription in treating COPD exacerbations, a trial showed.

Prof. Bafadhel: “This new approach should be implemented in the guidelines"

“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 OCS2,3. The multicentre, double-blind, randomised placebo-controlled STARR2 trial (NCT04458636) aimed to confirm these results1. 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, patients 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 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, FEV1 results, CAT scores, and 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 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.