skip to main content

Chronic obstructive pulmonary disease — SCE Respiratory MCQ

Instant feedback + full explanation. One question, done properly.

HardICS WithdrawalChronic obstructive pulmonary diseaseSCE Respiratory

A 71-year-old man with smoking-related COPD is reviewed to consider inhaled corticosteroid withdrawal. Two years ago, after two oral-corticosteroid-treated COPD exacerbations within 12 months, he changed from LAMA/LABA to fluticasone furoate/umeclidinium/vilanterol. He has subsequently had no COPD exacerbation for 18 months, and his breathlessness remains stable at mMRC grade 2. He has no previous diagnosis of asthma, atopy, marked symptom variability or nocturnal symptoms. Post-bronchodilator FEV1 is 46% predicted, with an increase of 90 mL and 6% from baseline. Inhaler technique and adherence are satisfactory. Blood eosinophil counts obtained during clinical stability 8 and 4 months ago were 330 and 370 cells/μL, respectively, without recent systemic corticosteroid exposure. Ten days before this review, he completed 5 days of prednisolone 30 mg daily for acute gout. His blood eosinophil count today is 60 cells/μL. He wishes to reduce his inhaled treatment because he has remained well. Which inhaled treatment plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Continue maintenance ICS/LAMA/LABA and disregard the recent eosinophil count when assessing withdrawal

Explanation lettering: E = shown as A · C = shown as B · A = shown as C · B = shown as D · D = shown as E

Although the absence of exacerbations for 18 months would ordinarily make ICS withdrawal reasonable to consider, his reproducible eosinophil counts of at least 300 cells/μL are the decisive exception. ERS guidance strongly recommends against ICS withdrawal in COPD at this threshold, irrespective of whether frequent exacerbations occurred during the preceding year, because withdrawal increases moderate or severe exacerbations in this subgroup. The current count of 60 cells/μL is unsuitable for de-escalation decisions because it was measured shortly after systemic corticosteroid treatment, which suppresses circulating eosinophils. It does not supersede two valid measurements obtained during clinical stability. A is therefore inappropriate despite his recent stability. C is also inappropriate: gradual withdrawal does not overcome the eosinophil-associated risk, and tapering is not generally required when withdrawal is otherwise appropriate. D preserves ICS but removes effective long-acting bronchodilation without a clinical indication. E recognises that the current count is unreliable, but a single later value below 300 cells/μL should not be used to negate the consistent historical eosinophilic phenotype. NICE additionally advises documenting the reason for continued ICS and reviewing it at least annually; in this case, the reason is the reproducible high blood eosinophil count and associated withdrawal risk.

Reference: Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline (2020) — https://publications.ersnet.org/content/erj/55/6/2000351 Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115) — Recommendations (2019) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial (2016) — https://pubmed.ncbi.nlm.nih.gov/27066739/