Initial treatment regimen and risk of hospitalization in patients with chronic obstructive pulmonary disease

Observational Studies of Inhaled Corticosteroid Effectiveness in COPD: Lessons Learned

BACKGROUND

Randomized controlled trials at times investigate findings suggested by observational studies. For example, the Towards a Revolution in COPD Health (TORCH) trial, which did not show a mortality reduction with inhaled corticosteroids (ICS) in COPD, was motivated by some observational studies that suggested considerable reductions in mortality with these drugs. Reasons for these discrepancies are unclear.

METHODS

The literature was searched to identify all observational studies, including cohort and case-control studies, investigating the effectiveness of ICS on major outcomes in patients with COPD; these outcomes included death and hospitalization for COPD.

RESULTS

A total of 21 studies were identified. Nine studies were affected by immortal time bias, five by immeasurable time bias, and seven by the "asthma factor" bias; some studies were affected by more than one bias. These studies found important reductions in the rates of major COPD outcomes with ICS use, with pooled rate ratios of 0.71 (95% CI, 0.67-0.76), 0.76 (95% CI, 0.70-0.83), and 0.79 (95% CI, 0.73-0.87), respectively, for the three sources of bias. In contrast, the five studies unaffected by these major biases did not find an association (pooled rate ratio, 1.02 [95% CI, 0.88-1.17]).

CONCLUSIONS

Observational studies are important to provide evidence from real-world data on medication effects. However, appropriate study design and analysis are essential to avoid biases and ensure randomized trials with greater chances of success. The observational studies suggesting potential beneficial effects of nonrespiratory drugs to treat COPD, such as statins and beta-blockers, will also need careful review before long and expensive randomized trials are conducted.

Comparative cost-effectiveness of a fluticasone-propionate/salmeterol combination versus anticholinergics as initial maintenance therapy for chronic obstructive pulmonary disease

PURPOSE

Relative costs and utilization-related outcomes of a fluticasone propionate 250 μg + salmeterol 50 μg combination (FSC), tiotropium bromide, and ipratropium as initial maintenance therapy in COPD have not been compared in a commercially-insured population.

METHODS

This retrospective, observational cohort study used health care claims data from January 2004 to June 2009 from a large administrative database for patients aged ≥40 years with COPD. Time-to-first COPD-related health care event beginning 30 days following therapy initiation with FSC (n = 16,684), ipratropium alone or in fixed dose combination with albuterol (n = 14,449), or tiotropium (n = 12,659) was estimated using Cox proportional hazard models that controlled for differences in patient demographic characteristics, health care utilization, and comorbidities at baseline. Mean adjusted costs and numbers of COPD-related health care encounters and prescription medication fills were compared among patients with 12 months of follow-up (FSC, n = 12,595; ipratropium, n = 10,617; tiotropium, n = 9126).

RESULTS

With FSC as the reference, risk for a COPD-related hospitalization and/or emergency department visit was significantly higher for ipratropium (hazard ratio [HR] 1.64, 95% confidence interval [CI] 1.50-1.79) and tiotropium (HR 1.29, CI 1.17-1.41). Mean adjusted 12-month COPD-related total health care costs were lower for FSC ($2068, standard deviation [SD] $1190) than for ipratropium ($2841, SD $1858) and tiotropium ($2408, SD $1511, both P <0.05). Mean number of COPD-related hospitalizations, emergency department visits, and outpatient visits associated with an oral corticosteroid or antibiotic were also lower for FSC than for ipratropium and tiotropium (all P <0.05).

CONCLUSIONS

In this retrospective "real-world" observational sample of COPD patients, initiating treatment with FSC was associated with significantly better clinical and economic outcomes compared with short- and long-acting anticholinergic therapy. Consistent with the goal of preventing and reducing exacerbations advocated by global guidelines, the findings suggest that initiation of maintenance treatment with FSC may afford clinical benefits at a lower cost than anticholinergic treatment.

The role of fluticasone propionate/salmeterol combination therapy in preventing exacerbations of COPD

Exacerbations contribute significantly to the morbidity of COPD, leading to an accelerated decline in lung function, reduced functional status, reduced health status and quality of life, poorer prognosis and increased mortality. Prevention of exacerbations is thus an important goal of COPD management. In patients with COPD, treatment with a combination of the inhaled corticosteroid fluticasone propionate (250 microg) and the long-acting beta(2)-agonist salmeterol (50 microg) in a single inhaler (250/50 microg) is an effective therapy option that has been shown to reduce the frequency of exacerbations, to improve lung function, dyspnea and health status, and to be relatively cost-effective as a COPD maintenance therapy. Importantly, results of various studies suggest that fluticasone propionate and salmeterol have synergistic effects when administered together that improve their efficacy in controlling symptoms and reducing exacerbations. The present non-systematic review summarizes the role of fluticasone propionate/salmeterol combination therapy in the prevention of exacerbations of COPD and its related effects on lung function, survival, health status, and healthcare costs.

Clinical Safety of Long-Acting β2-Agonist and Inhaled Corticosteroid Combination Therapy in COPD

Long-acting beta2-agonist (LABA) and inhaled corticosteroid (ICS) combination therapy is recommended by international treatment guidelines for COPD. The current literature concerning the safety of LABAs and ICS, both as monotherapies and in combination, in patients with COPD is reviewed. Bronchodilators such as LABAs are key treatments for COPD due to their effects on bronchial smooth muscle and airflow limitation. LABAs are well-tolerated in patients with COPD, with a low incidence of reported adverse events (AEs). Most AEs associated with LABA use are due to systemic exposure and include muscle tremor and cardiac effects. Placebo-controlled studies in patients with COPD demonstrate that there is no increase in risk of cardiac AEs with LABA therapy. ICS therapy targets airway inflammation in COPD, and is associated with a reduction in the frequency of COPD exacerbations, and improvements in symptoms, lung function and health status. Localized effects such as oropharyngeal irritation are common with ICS, but are not considered to be serious. Potential ocular effects with ICS therapy in patients with COPD have been identified and require further investigation. Rare, but more serious AEs related to ICS use are the effects on bone and the suppression of endogenous cortisol production; however, the clinical relevance of these effects is unclear. Clinical data indicate that LABA/ICS combination therapy is more effective in COPD than either agent used alone and is not associated with any additional AEs.

Seretide: a pharmacoeconomic analysis

BACKGROUND

The costs of asthma and chronic obstructive pulmonary disease (COPD), the two most common chronic respiratory illnesses, are substantial and rising. The fixed-dose combination of fluticasone and salmeterol has been a safe and effective therapy for these diseases.

OBJECTIVES

To review the pharmacoeconomic impact of the fixed-dose combination of inhaled fluticasone and salmeterol in asthma and COPD.

METHODS

A systematic review of the literature was carried out to identify pharmacoeconomic studies with fixed-dose salmeterol and fluticasone (Seretide, Advair, Viani). In addition, abstracts from recent respiratory meetings were sought, and any unpublished data were requested from the manufacturer.

RESULTS

For asthma, when compared to treatment with inhaled corticosteroid monotherapy and antileukotrienes, alone or combined, salmeterol/fluticasone inhalation produced a higher proportion of successfully treated weeks, improvement in lung function and quality of life, and fewer treatment failures. The costs per quality-adjusted life year (QALY) for fluticasone/salmeterol have been favourable not only in patients with moderate to severe disease but also in patients with mild disease or patients not previously treated with a maintenance therapy. The excess cost per QALY varied from US$2,670 to US$26,445. For COPD, a clear reduction in exacerbation rates and improvement in quality of life has been demonstrated with salmeterol/fluticasone along with a likely improvement in survival rates. The incremental cost per QALY ratio for fluticasone/salmeterol against placebo ranged from US$9,512 to US$64,038.

CONCLUSIONS

The data currently available suggest that the cost effectiveness of combination therapy with fluticasone and salmeterol is favourable for asthma and COPD in a variety of clinical settings.