Is it time to give up on “self-management” of COPD exacerbations?

To the Editor:

We read with interest the report of the results of the COPE-III trial by Lenferink et al. [1]. This large randomised trial continues on from the authors’ earlier COPE-II study [2], with personalised exacerbation action plans based on associated comorbidities. The action plans were detailed, and designed to determine symptom changes and the signs of an ensuing exacerbation. The study was negative for its primary endpoint (COPD exacerbation days) and no improvement in quality of life was found using the self-management intervention. The authors show no difference in the number of oral prednisolone courses in both arms, although per exacerbation event, it is clear that self-management dictates a significant increase of prednisolone prescription per event (95% (208/216) versus 71% (163/230)) and thus would have also been the initial treatment for heart failure, anxiety, depression and ischaemic heart disease events. Interestingly, the authors found that patients that benefited in the self-management arm were those that had one or more COPD exacerbations in the 12-month study period. We now know that eosinophilic inflammation is associated with increased risk of exacerbations [3] and that patients that have the best response to systemic corticosteroids have eosinophilic exacerbations [4]. We ask with interest if the authors phenotyped inflammation of the COPD patients prior to randomisation?

Undoubtedly pharmacotherapy should reflect the underlying cause, and although the authors move towards achieving this, it is difficult to be confident that self-management during symptom deterioration of COPD leads to accurate treatment to match the underlying cause. This might explain these and other findings of increased harm in interventions associated with self-management [5, 6]. Although Lenferink et al. [1] make a significant step in trying to manage comorbidities in their programme, systemic corticosteroids are the predominant treatment in the self-management intervention: a highly toxic and potentially ineffective intervention [7]. In parallel to personalising treatment towards comorbidities, we believe that we should also be aiming at getting the right and best treatment to the patient first. Achieving this and improving outcomes in COPD is unlikely to occur, however, with current strategies directed towards self-management, where we have an unknown explanation for symptom worsening and toxic treatment.

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