Examining patterns of multimorbidity, polypharmacy and risk of adverse drug reactions in chronic obstructive pulmonary disease: a cross-sectional UK Biobank study

Modifiable risk factors that may be addressed in routine care to prevent progression to and extension of multimorbidity in people with COPD: a systematic literature review

Chronic obstructive pulmonary disease (COPD) is a multisystem disease, and many patients have multiple conditions. We explored multimorbidity patterns that might inform intervention planning to reduce health-care costs while preserving quality of life for patients. Literature searches up to February 2022 revealed 4419 clinical observational and comparative studies of risk factors for multimorbidity in people with COPD, pulmonary emphysema, or chronic bronchitis at baseline. Of these, 29 met the inclusion criteria for this review. Eight studies were cluster and network analyses, five were regression analyses, and 17 (in 16 papers) were other studies of specific conditions, physical activity and treatment. People with COPD more frequently had multimorbidity and had up to ten times the number of disorders of those without COPD. Disease combinations prominently featured cardiovascular and metabolic diseases, asthma, musculoskeletal and psychiatric disorders. An important risk factor for multimorbidity was low socioeconomic status. One study showed that many patients were receiving multiple drugs and had increased risk of adverse events, and that 10% of medications prescribed were inappropriate. Many patients with COPD have mainly preventable or modifiable multimorbidity. A proactive multidisciplinary approach to prevention and management could reduce the burden of care.

Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction

INTRODUCTION

The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI.

METHODS

This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted.

RESULTS

A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as "serious." Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16-200 days).

CONCLUSION

Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

Association between COVID-19 vaccines and development of chronic morbidities: a cross-sectional study in the Jordanian population

BACKGROUND

In Jordan, individuals recently diagnosed with chronic illnesses have expressed concerns with regard to COVID-19 vaccines. This study aims to investigate potential associations between COVID-19 vaccination and the likelihood of recipients developing chronic conditions such as autoimmune diseases, rheumatoid arthritis, diabetes, asthma, and hypertension.

METHODOLOGY

Through a cross-sectional survey-based descriptive approach, this research was conducted to gather data within the Jordanian context. A web-based survey was utilized to collect demographic information, record vaccine-related side effects, and document the chronic disease status subsequent to COVID-19 vaccination. Statistical analysis was employed to reveal any potential associations between the vaccine, its side effects, and the emergence of chronic morbidities.

RESULTS

The study involved 414 participants, among whom 10.4% exhibited pre-existing chronic diseases before vaccination. Remarkably, post-vaccination, 23.7% of participants were newly diagnosed with chronic illnesses. Statistical analysis indicated a significant correlation between COVID-19 vaccination and the subsequent development of chronic diseases (p-value ˂.01). the investigation found no significant association between vaccination and the emergence of diabetes, hypertension, or asthma (p-value ≥.01) However, an association was found between COVID-19 vaccination and the development of autoimmune diseases and rheumatoid arthritis (p-value ˂.01).

CONCLUSIONS

This study highlights an association between the occurrence of autoimmune diseases and COVID-19 vaccination, while findings related to diabetes, asthma, and hypertension did not display significant associations. The results emphasize the necessity for further research to ascertain potential causal relationship.

Perceptions of the effectiveness of non-pharmacological management of respiratory disorders among CRD patients

Chronic respiratory diseases (CRDs) are among the leading cause of mortality worldwide. While pharmacological approaches are commonly used to manage symptoms, non-pharmacological management of CRDs is considered crucial in preventing disease progression and improving patient self-efficacy. To describe the perceived effectiveness of non-pharmacological management of CRDs among CRD patients and determine whether the CRD patients perceptions of the effectiveness of non-pharmacological management are associated with their demographic characteristics. An analytic cross-sectional study design was utilized. The non-pharmacological management practices of CRD patients and their perception of the effectiveness of these therapeutic measures were assessed using a researcher-developed questionnaire. Data collection took place in primary healthcare centers in Al Ahsa, Saudi Arabia from October 2021 to March 2022. The proportion of CRD patients who perceived that non-pharmacological interventions were effective was computed. Binary logistic regression was performed to determine the association between the demographic characteristics of the respondents and their perception of the effectiveness of non-pharmacological management. Among the 390 respondents, 42% perceived that non-pharmacological measures were effective. Half of the respondents believed that smoking cessation, influenza vaccination, improving physical activity, and nutrition support helped alleviate CRD symptoms, while less than half of the respondents considered pulmonary rehabilitation, educational programs, and oxygen therapy effective measures to control symptoms. Women were found to be 3.24 times more likely to perceive non-pharmacological interventions as effective (P < .0000) compared to men. Those with university-level education were 66.6% less likely to consider non-pharmacological interventions to be effective (P < .0000) than those who completed preuniversity-level education. Age and marital status did not significantly influence perceptions of effectiveness. Differences in the perceptions of the effectiveness of various non-pharmacological measures to alleviate CRD symptoms existed among the CRD patients of Al Ahsa. The perception of effectiveness was significantly associated with the patient's gender and educational attainment.

Mapping inpatient care pathways for patients with COPD: an observational study using routinely collected electronic hospital record data

Introduction

Respiratory specialist ward care is associated with better outcomes for patients with COPD exacerbations. We assessed patient pathways and associated factors for people admitted to hospital with COPD exacerbations.

Methods

We analysed routinely collected electronic health data for patients admitted with COPD exacerbation in 2018 to Queen Elizabeth Hospital, Birmingham, UK. We extracted data on demographics, deprivation index, Elixhauser comorbidities, ward moves, length of stay, and in-hospital and 1-year mortality. We compared care pathways with recommended care pathways (transition from initial assessment area to respiratory wards or discharge). We used Markov state transition models to derive probabilities of following recommended pathways for patient subgroups.

Results

Of 42 555 patients with unplanned admissions during 2018, 571 patients were admitted at least once with an exacerbation of COPD. The mean±sd age was 51±11 years; 313 (55%) were women, 337 (59%) lived in the most deprived neighbourhoods and 45 (9%) were from non-white ethnic backgrounds. 428 (75.0%) had ≥4 comorbidities. Age >70 years was associated with higher in-hospital and 1-year mortality, more places of care (wards) and longer length of stay; having ≥4 comorbidities was associated with higher mortality and longer length of stay. Older age was associated with a significantly lower probability of following a recommended pathway (>70 years: 0.514, 95% CI 0.458-0.571; ≤70 years: 0.636, 95% CI 0.572-0.696; p=0.004).

Conclusions

Only older age was associated with a lower chance of following recommended hospital pathways of care. Such analyses could help refine appropriate care pathways for patients with COPD exacerbations.

European Respiratory Society statement on frailty in adults with chronic lung disease

Frailty is a complex, multidimensional syndrome characterised by a loss of physiological reserves that increases a person's susceptibility to adverse health outcomes. Most knowledge regarding frailty originates from geriatric medicine; however, awareness of its importance as a treatable trait for people with chronic respiratory disease (including asthma, COPD and interstitial lung disease) is emerging. A clearer understanding of frailty and its impact in chronic respiratory disease is a prerequisite to optimise clinical management in the future. This unmet need underpins the rationale for undertaking the present work. This European Respiratory Society statement synthesises current evidence and clinical insights from international experts and people affected by chronic respiratory conditions regarding frailty in adults with chronic respiratory disease. The scope includes coverage of frailty within international respiratory guidelines, prevalence and risk factors, review of clinical management options (including comprehensive geriatric care, rehabilitation, nutrition, pharmacological and psychological therapies) and identification of evidence gaps to inform future priority areas of research. Frailty is underrepresented in international respiratory guidelines, despite being common and related to increased hospitalisation and mortality. Validated screening instruments can detect frailty to prompt comprehensive assessment and personalised clinical management. Clinical trials targeting people with chronic respiratory disease and frailty are needed.

Predicting Development of Chronic Obstructive Pulmonary Disease and its Risk Factor Analysis

Chronic Obstructive Pulmonary Disease (COPD) is an irreversible airway obstruction with a high societal burden. Although smoking is known to be the biggest risk factor, additional components need to be considered. In this study, we aim to identify COPD risk factors by applying machine learning models that integrate sociodemographic, clinical, and genetic data to predict COPD development.Clinical relevance- This study assessed the risk factors of COPD in sociodemographic, clinical, and genetic data. We have determined that sociodemographic factors are highly associate to the development of COPD.

Analyzing determinants from both compositional and contextual level impeding desired linear growth of children in Indian context

Childhood stunting is recognized as significant public health concern in India. It is a form of malnutrition with impaired linear growth and creates a range of adversaries among children, including under-5 mortality, morbidity, and physical and cognitive growth. The purpose of the present study was to recognize the various leading determinants causing childhood stunting from both individual and contextual level in Indian context. Data were obtained from the India's Demography and Health Survey (DHS) conducted in 2019-2021. A total of 1, 46,521 children aged 0-59 months were included in this present study. The study applied a multilevel mixed-effect logistic regression model in which individual factors nested within community based contextual-level factors estimating the likelihood of childhood stunting phenomena among Indian children. The variance explained in full model accounted for about 35.8% of the odds of stunting across the communities. The present study elucidates that the recognized factors from individual level characteristics have really increased the odds of childhood stunting: gender of child, multiple births, low birth weight, low BMI among mothers, less educational attainment by mothers, maternal anemic status, breast feeding duration longer than usual, < 4 antenatal care (ANC) visits during gestation period. Similarly, contextual-level factors like rural places of residence, western Indian children, and communities with high poverty rates, lower literacy rates, improper sanitation, and unsafe drinking water were also found to have a significant positive association with childhood stunting. The study finally concludes that cross level interaction between individual and contextual-level factors are identified as significant determinants of linear growth retardation among child in India. In order to reduce this type of malnutrition among the child one should more concentrate on both individual and contextual-level factors as a notable reasons.

Rehabilitation for People with Respiratory Disease and Frailty: An Official American Thoracic Society Workshop Report

People with respiratory disease have increased risk of developing frailty, which is associated with worse health outcomes. There is growing evidence of the role of rehabilitation in managing frailty in people with respiratory disease. However, several challenges remain regarding optimal methods of identifying frailty and delivering rehabilitation for this population. The aims of this American Thoracic Society workshop were to outline key definitions and concepts around rehabilitation for people with respiratory disease and frailty, synthesize available evidence, and explore how programs may be adapted to align to the needs and experiences of this population. Across two half-day virtual workshops, 20 professionals from diverse disciplines, professions, and countries discussed key developments and identified opportunities for future research, with additional input via online correspondence. Participants highlighted a "frailty rehabilitation paradox" whereby pulmonary rehabilitation can effectively reduce frailty, but programs are challenging for some individuals with frailty to complete. Frailty should not limit access to rehabilitation; instead, the identification of frailty should prompt comprehensive assessment and tailored support, including onward referral for additional specialist input. Exercise prescriptions that explicitly consider symptom burden and comorbidities, integration of additional geriatric or palliative care expertise, and/or preemptive planning for disruptions to participation may support engagement and outcomes. To identify and measure frailty in people with respiratory disease, tools should be selected on the basis of sensitivity, specificity, responsiveness, and feasibility for their intended purpose. Research is required to expand understanding beyond the physical dimensions of frailty and to explore the merits and limitations of telerehabilitation or home-based pulmonary rehabilitation for people with chronic respiratory disease and frailty.

Nonpharmacological management of psychological distress in people with COPD

Psychological distress is prevalent in people with COPD and relates to a worse course of disease. It often remains unrecognised and untreated, intensifying the burden on patients, carers and healthcare systems. Nonpharmacological management strategies have been suggested as important elements to manage psychological distress in COPD. Therefore, this review presents instruments for detecting psychological distress in COPD and provides an overview of available nonpharmacological management strategies together with available scientific evidence for their presumed benefits in COPD. Several instruments are available for detecting psychological distress in COPD, including simple questions, questionnaires and clinical diagnostic interviews, but their implementation in clinical practice is limited and heterogeneous. Moreover, various nonpharmacological management options are available for COPD, ranging from specific cognitive behavioural therapy (CBT) to multi-component pulmonary rehabilitation (PR) programmes. These interventions vary substantially in their specific content, intensity and duration across studies. Similarly, available evidence regarding their efficacy varies significantly, with the strongest evidence currently for CBT or PR. Further randomised controlled trials are needed with larger, culturally diverse samples and long-term follow-ups. Moreover, effective nonpharmacological interventions should be implemented more in the clinical routine. Respective barriers for patients, caregivers, clinicians, healthcare systems and research need to be overcome.

Experience of living with multimorbidity and health workers perspectives on the organization of health services for people living with multiple chronic conditions in Bahir Dar, northwest Ethiopia: a qualitative study

BACKGROUND

Multimorbidity-the simultaneous occurrence of two or more chronic Non-Communicable Diseases) in an individual is increasing globally and challenging health systems. Although individuals living with multimorbidity face a range of adverse consequences and difficulty in getting optimal health care, the evidence base in understanding the burden and capacity of the health system in managing multimorbidity is sparse in low-and middle-income countries (LMICs). This study aimed at understanding the lived experiences of patients with multimorbidity and perspective of service providers on multimorbidity and its care provision, and perceived capacity of the health system for managing multimorbidity in Bahir Dar City, northwest Ethiopia.

METHODS

A facility-based phenomenological study design was conducted in three public and three private health facilities rendering chronic outpatient Non-Communicable Diseases (NCDs) care in Bahir Dar City, Ethiopia. Nineteen patient participants with two or more chronic NCDs and nine health care providers (six medical doctors and three nurses) were purposively selected and interviewed using semi-structured in-depth interview guides. Data were collected by trained researchers. Interviews were audio-recorded using digital recorders, stored and transferred to computers, transcribed verbatim by the data collectors, translated into English and then imported into NVivo V.12 software for data analysis. We employed a six-step inductive thematic framework analysis approach to construct meaning and interpret experiences and perceptions of individual patients and service providers. Codes were identified and categorized into sub-themes, organizing themes and main themes iteratively to identify similarities and differences across themes, and to interpret them accordingly.

RESULTS

A total of 19 patient participants (5 Females) and nine health workers (2 females) responded to the interviews. Participants' age ranged from 39 to 79 years for patients and 30 to 50 years for health professionals. About half (n = 9) of the participants had three or more chronic conditions. The key themes produced were feeling dependency, social rejection, psychological distress, poor medication adherence and poor quality of care. Living with multimorbidity poses a huge burden on the physical, psychological, social and sexual health of patients. In addition, patients with multimorbidity are facing financial hardship to access optimal multimorbidity care. On the other hand, the health system is not appropriately prepared to provide integrated, person-centered and coordinated care for people living with multiple chronic conditions.

CONCLUSION AND RECOMMENDATIONS

Living with multimorbidity poses huge impact on physical, psychological, social and sexual health of patients. Patients seeking multimorbidity care are facing challenges to access care attributable to either financial constraints or the lack of integrated, respectful and compassionate health care. It is recommended that the health system must understand and respond to the complex care needs of the patients with multimorbidity.

Evaluation of Drug Interactions in Hospitalized Patients with Respiratory Disorders in Greece

Background: Patients with respiratory disorders often have additional diseases and are usually treated with more than one medication to manage their respiratory conditions as well as additional comorbidities. Thus, they are frequently exposed to polypharmacy (≥5 drugs), which raises the risk for drug-drug interactions (DDIs) and adverse drug reactions (ADRs). In this work, we present the results regarding the prevalence of DDIs in hospitalized patients with respiratory disorders in Greece. Methods: A 6-month descriptive single-center retrospective observational study enrolled 102 patients with acute or chronic respiratory disorders. Clinical characteristics and medication regimens were recorded upon admission, hospitalization, and discharge. The prevalence of DDIs and their clinical significance was recorded and analyzed. Results: Unspecified acute lower respiratory tract infection (25%), exacerbations of chronic obstructive pulmonary disease (12%) and pneumonia (8%) were the most frequent reasons for admission. Cardiovascular disorders (46%), co-existing respiratory disorders (32%), and diabetes (25%) were the most prevalent comorbidities. Polypharmacy was noted in 61% of patients upon admission, 98% during hospitalization, and 63% upon discharge. Associated DDIs were estimated to be 55% upon admission, 96% throughout hospitalization, and 63% on discharge. Pharmacodynamic (PD) DDIs were the most prevalent cases (81%) and referred mostly to potential risk for QT-prolongation (31.4% of PD-DDIs) or modulation of coagulation process as expressed through the international normalized ratio (INR) (29.0% of DDIs). Pharmacokinetic (PK) DDIs (19% of DDIs) were due to inhibition of Cytochrome P450 mediated metabolism that could lead to elevated systemic drug concentrations. Clinically significant DDIs characterized as "serious-use alternative" related to 7% of cases while 59% of DDIs referred to combinations that could be characterized as "use with caution-monitor". Clinically significant DDIs mostly referred to medication regimens upon admission and discharge and were associated with outpatient prescriptions. Conclusions: Hospitalized patients with respiratory disorders often experience multimorbidity and polypharmacy that raise the risk of DDIs. Clinicians should be conscious especially if any occurring arrhythmias, INR modulations, and prolonged or increased drug action is associated with DDIs.

Geriatrician-led multidisciplinary team management improving polypharmacy among older inpatients in China

Background/Aim: Polypharmacy is prevalent among older inpatients and associated with adverse outcomes. To determine whether a geriatrician-led multidisciplinary team (MDT) management mode could reduce medications use among older inpatients. Methods: A retrospective cohort study was conducted in a geriatric department of a tertiary hospital in China with 369 older inpatients, including 190 patients received MDT management (MDT cohort), and 179 patients received usual treatment (non-MDT cohort). The primary outcome was to compare the changes of the amount of medications before and after hospitalization in two cohorts. Results: We reported that MDT management significantly reduced the number of medications used in older inpatients at discharge (at home: n = 7 [IQR: 4, 11] vs at discharge: n = 6 [IQR: 4, 8], p < 0.05). Hospitalization with the MDT management had a significant effect on the change in the amount of medications (F = 7.813, partial-η² = 0.011, p = 0.005). The discontinuance of medications was associated with polypharmacy at home (OR: 96.52 [95% CI: 12.53-743.48], p < 0.001), and the addition of medications was associated with a diagnosis of chronic obstructive pulmonary disease (COPD) (OR: 2.36 [95% CI: 1.02-5.49], p = 0.046). Conclusion: The results indicated that the geriatrician-led MDT mode during hospitalization could reduce the number of medications used by older patients. The patients with polypharmacy were more likely to "deprescription" after MDT management, while the patients with COPD were more likely to be under-prescription at home, polypharmacy which could be made up for after MDT management.

Inhalation therapies in COPD - adverse drug reactions impact on emergency department presentations

PURPOSE

Inhaled drugs have been cornerstones in the treatment of chronic obstructive pulmonary disease (COPD) for decades and show a high prescription volume. Due to the local application, drug safety issues of these therapies are often underestimated by professionals and patients. Data about adverse drug reactions (ADRs) caused by inhaled therapy in patients with COPD and polypharmacy are rare. We aimed to analyze the use and relevance of inhaled therapies in those patients in relation to ADR complaints, which were severe enough to warrant presentation to the emergency department.

METHODS

Emergency department cases due to suspected ADRs of the ADRED database (n = 2939, "Adverse Drug Reactions in Emergency Departments"; DRKS-ID: DRKS00008979, registration date 01/11/2017) were analyzed for inhaled drugs in patients with COPD. ADRs in cases with overdosed inhaled drugs were compared to non-overdosed cases. ADRs, potentially caused by inhaled drugs, were evaluated, clustered into complexes, and assessed for association with inhaled drug classes.

RESULTS

Of the 269 included COPD cases, 67% (n = 180) received inhaled therapy. In 16% (n = 28), these therapies were overdosed. Overdosed cases presented the complexes of malaise and local symptoms more frequently. Related to the use of inhaled anticholinergics, local (dysphagia-like) and related to inhaled beta-2 agonists, local (dysphagia-like) and sympathomimetic-like ADRs presented more frequently.

CONCLUSION

Overdosed inhaled therapies in patients with COPD lead to relevant ADRs and impact on emergency room presentations. These are rarely associated to inhaled therapy by healthcare professionals or patients. Due to the high volume of inhaled drug prescriptions, pharmacovigilance and patient education should be more focused in patients with COPD. German Clinical Trial Register: DRKS-ID: DRKS00008979.

Surveillance of Side Effects after Two Doses of COVID-19 Vaccines among Patients with Comorbid Conditions: A Sub-Cohort Analysis from Saudi Arabia

Background: Individuals with underlying chronic illnesses have demonstrated considerable hesitancy towards COVID-19 vaccines. These concerns are primarily attributed to their concerns over the safety profile. Real-world data on the safety profile among COVID-19 vaccinees with comorbid conditions are scarce. This study aimed to ascertain the side-effects profile after two doses of COVID-19 vaccines among chronic-disease patients. Methodology: A cross-sectional questionnaire-based study was conducted among faculty members with comorbid conditions at a public educational institute in Saudi Arabia. A 20-item questionnaire recorded the demographics and side effects after the two doses of COVID-19 vaccines. The frequency of side effects was recorded following each dose of vaccine, and the association of the side-effects score with the demographics was ascertained through appropriate statistics. Results: A total of 204 patients with at least one comorbid condition were included in this study. A total of 24 side effects were reported after the first dose and 22 after second dose of the COVID-19 vaccine. The incidence of at least one side effect was 88.7% and 95.1% after the first and second doses of the vaccine, respectively. The frequent side effects after the first dose were pain at the injection site (63.2%), fatigue (58.8%), fever (47.5%), muscle and joint pain (38.7%), and headache (36.3%). However, pain at the injection site (71.1%), muscle and joint pain (62.7%), headache (49.5%), fever (45.6%), and stress (33.3%) were frequent after the second dose. The average side-effects score was 4.41 ± 4.18 (median: 3, IQR: 1, 6) and 4.79 ± 3.54 (median 4, IQR: 2, 6) after the first and second dose, respectively. Female gender, diabetes mellitus, hypertension, hyperlipidemia, comorbidity > 2, family history of COVID-19, and the AstraZeneca vaccine were significantly associated with higher side-effect scores. Only 35.8% of study participants were satisfied with the safety of COVID-19 vaccines. Conclusions: Our analysis showed a high proportion of transient and short-lived side effects of Pfizer and AstraZeneca vaccines among individuals with chronic illnesses. However, the side-effects profile was comparable with the safety reports of phase 3 clinical trials of these vaccines. The frequency of side effects was found to be associated with certain demographics, necessitating the need for further investigations to establish a causal relationship. The current study’s findings will help instill confidence in the COVID-19 vaccines among people living with chronic conditions, overcome vaccine hesitancy, and increase vaccine coverage in this population.

Polypharmacy and potential drug–drug interactions among Greenland’s care home residents

Background:

As lifetime expectancy in Greenland is steadily increasing, so is the proportion of elderly Greenlanders. Old age is associated with polypharmacy, and in this study, we aim to describe the prevalence and characteristics of polypharmacy among the care home residents in Greenland.

Methods:

Eight care homes in Greenland were visited between 2010 and 2016. Questionnaires including information on prescribed medication and comorbidities were collected and analyzed. Drugs were categorized according to Anatomical Therapeutic Chemical (ATC) category, and potential drug–drug interactions (pDDIs) were assessed using the Danish Interaction Database. Polypharmacy was defined as five or more prescribed drugs.

Results:

All 244 eligible residents were included in the study. The median number of prescribed drugs per resident was six, and women were prescribed more drugs than men (median six versus five). More than 60% of all residents fulfilled the criteria for polypharmacy. The residents in the polypharmacy group had a higher body mass index (26.9 versus 24.3) and more chronic diseases (median two versus one), and more often pulmonary (14% versus 1%) or endocrine disease (22% versus 2%) than in the non-polypharmacy group. The most prescribed drugs belonged to ATC category N (nervous system, 78% of the residents). Finally, pDDIs were found among 61% of the residents and were more common in the capital (77%), which also had the highest proportion of residents with polypharmacy (77%).

Conclusion:

This is the first study to describe the patterns of polypharmacy and pDDIs among the elderly in care homes in Greenland. Our findings indicate that polypharmacy is as common in Greenland as elsewhere in the Western world, but there are local differences in the prevalence.

Plain Language Summary

Polypharmacy among the elderly in care homes in Greenland

The lifetime expectancy of the Greenlandic population is increasing, and so is the number of elderly Greenlanders. Previous studies have shown that the elderly have a higher risk of being treated with five drugs or more which is called polypharmacy. Polypharmacy can cause unwanted interactions and side effects. In this study, we examine the characteristics of the residents in Greenlandic care homes belonging to this group.

Using questionnaires, we gathered information from 244 residents from care homes in eight different towns and settlements in Greenland. Data included types of medication prescribed to the resident, age, gender, cause of stay, and medical history, which allowed us to compare the results between genders and towns.

We found that among 244 residents, more than half of all residents were prescribed five or more different drugs, and women were generally prescribed more drugs than men. Those prescribed five or more drugs had a higher body mass index and more diseases than those prescribed fewer drugs. We also found that certain types of medication, mainly painkillers, were the most prescribed. Finally, residents in the care home in Greenland’s capital Nuuk were more often prescribed five or more drugs than elsewhere in Greenland, indicating local differences in Greenland.

Our results give an essential insight into the health and medication of the most fragile elderly in Greenland. Polypharmacy seems to be as common here as elsewhere in the Western world and is a point of focus.

Multimorbidity and adverse events of special interest associated with Covid-19 vaccines in Hong Kong

Prior research using electronic health records for Covid-19 vaccine safety monitoring typically focuses on specific disease groups and excludes individuals with multimorbidity, defined as ≥2 chronic conditions. We examine the potential additional risk of adverse events 28 days after the first dose of CoronaVac or Comirnaty imposed by multimorbidity. Using a territory-wide public healthcare database with population-based vaccination records in Hong Kong, we analyze a retrospective cohort of patients with chronic conditions. Thirty adverse events of special interest according to the World Health Organization are examined. In total, 883,416 patients are included and 2,807 (0.3%) develop adverse events. Results suggest vaccinated patients have lower risks of adverse events than unvaccinated individuals, multimorbidity is associated with increased risks regardless of vaccination, and the association of vaccination with adverse events is not modified by multimorbidity. To conclude, we find no evidence that multimorbidity imposes extra risks of adverse events following Covid-19 vaccination.

Clinical characteristics and outcomes of polypharmacy in chronic obstructive pulmonary disease patients: A cross-sectional study from Crete, Greece

OBJECTIVES

Polypharmacy and multimorbidity in chronic obstructive pulmonary disease (COPD) are highly prevalent, with potential associations with worse COPD outcomes. The aim of this study was to identify the clinical characteristics and outcomes of polypharmacy, investigate the relationship of polypharmacy with health status and exacerbations and assess the prevalence of inappropriate medication (PIM), risk of adverse drug reactions (ADRs) and drug-to-drug interactions in COPD patients.

METHODS

A total of 245 COPD patients were enrolled from primary care in Crete, Greece. Patients completed a questionnaire and the COPD Assessment Test (CAT). Multimorbidity was defined as having two or more comorbidities and polypharmacy was defined as taking five or more drugs per day.

RESULTS

Most of COPD patients (77.0%) and the majority (83.6%) of elderly (≥65 years) had multimorbidity, while polypharmacy was evident in 55.2% of all patients and 62.4% in elderly. After adjustments for age, gender and pack-years, polypharmacy was associated with CAT ≥ 10, multimorbidity, several cardiometabolic diseases, cancer and depression-anxiety and prostate disorders (all p values > 0.05). PIMs were found in 9.6% of subjects aged ≥65 years and were mainly mental health medication. Due to coadministration of medications, 22.3% of the population were at cumulative risk for falls, 17% for constipation and 12.8% for cardiovascular events. Finally, 15 pairs of drug-to-drug interactions were identified in 11.5% of patients.

CONCLUSION

Our data suggest that polypharmacy is highly prevalent and associated with worse health status and prescription risks in COPD patients. These findings potentially introduce an additional challenge on effective management of these patients.

Health information technology to improve care for people with multiple chronic conditions

OBJECTIVE

To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps.

DATA SOURCES

We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020.

STUDY DESIGN

We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making.

DATA COLLECTION/EXTRACTION METHODS

Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers.

PRINCIPAL FINDINGS

The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality.

CONCLUSIONS

Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.

Factors associated with medication adherence among people living with COPD: Pharmacists' perspectives

Background

While medication is an integral part of the effective management of COPD, more than 50% of people living with COPD do not adhere to their prescribed medications. The drivers underpinning this observed behaviour are poorly understood. As pharmacists generally have the final interaction with patients prior to their use of medications, their perspectives may offer insights about patients' medication use that may improve our understanding of this complex issue.

Objective

This study explored pharmacists' experiences of providing care for patients living with COPD to gain insight about factors that impact their medication-taking behaviour.

Methods

Fourteen pharmacists who worked in practice settings across the South-East Queensland region of Australia participated in interviews between March 2019 and January 2020. Interviews were audio-recorded, transcribed verbatim, and thematically analysed.

Results

Two overarching themes were identified which modulated medication-taking behaviour. Barriers comprised patient-related factors including, financial constraints, poor inhaler technique, and inaccurate beliefs; alongside pharmacist-related factors such as a lack of COPD-specific training and time constraints. Factors that promote adherence included patient education and monitoring and collaborative relationships between key stakeholders.

Conclusions

Medication non-adherence is common. While pharmacists expressed a desire to better support their patients, practical strategies to overcome the challenges that they face in clinical settings are lacking. Future research should focus on exploring ways to engage patients at the pharmacy level thereby enhancing the provision of services that would optimise medication adherence.

Phenotypic Clustering in Non-Cystic Fibrosis Bronchiectasis Patients: The Role of Eosinophils in Disease Severity

Whether high blood eosinophil counts may define a better phenotype in bronchiectasis patients, as shown in chronic obstructive pulmonary disease (COPD), remains to be investigated. Differential phenotypic characteristics according to eosinophil counts were assessed using a biostatistical approach in a large cohort study from the Spanish Online Bronchiectasis Registry (RIBRON). The 906 patients who met the inclusion criteria were clustered into two groups on the basis of their eosinophil levels. The potential differences according to the bronchiectasis severity index (BSI) score between two groups (Mann–Whitney U test and eosinophil count threshold: 100 cells/µL) showed the most balanced cluster sizes: above-threshold and below-threshold groups. Patients above the threshold exhibited significantly better clinical outcomes, lung function, and nutritional status, while showing lower systemic inflammation levels. The proportion of patients with mild disease was higher in the above-threshold group, while the below-threshold patients were more severe. Two distinct clinical phenotypes of stable patients with non-cystic fibrosis (CF) bronchiectasis of a wide range of disease severity were established on the basis of blood eosinophil counts using a biostatistical approach. Patients classified within the above-threshold cluster were those exhibiting a mild disease, significantly better clinical outcomes, lung function, and nutritional status while showing lower systemic inflammatory levels. These results will contribute to better characterizing bronchiectasis patients into phenotypic profiles with their clinical implications.

Prevalence, management and impact of chronic obstructive pulmonary disease in atrial fibrillation: a systematic review and meta-analysis of 4,200,000 patients

AIM

Prevalence of chronic obstructive pulmonary disease (COPD) in atrial fibrillation (AF) patients is unclear, and its association with adverse outcomes is often overlooked. Our aim was to estimate the prevalence of COPD, its impact on clinical management and outcomes in patients with AF, and the impact of beta-blockers (BBs) on outcomes in patients with COPD.

METHODS AND RESULTS

A systematic review and meta-analysis was conducted according to international guidelines. All studies reporting the prevalence of COPD in AF patients were included. Data on comorbidities, BBs and oral anticoagulant prescription, and outcomes (all-cause death, cardiovascular (CV) death, ischaemic stroke, major bleeding) were compared according to COPD and BB status. Among 46 studies, pooled prevalence of COPD was 13% [95% confidence intervals (CI) 10-16%, 95% prediction interval 2-47%]. COPD was associated with higher prevalence of comorbidities, higher CHA2DS2-VASc score and lower BB prescription [odds ratio (OR) 0.77, 95% CI 0.61-0.98]. COPD was associated with higher risk of all-cause death (OR 2.22, 95% CI 1.93-2.55), CV death (OR 1.84, 95% CI 1.39-2.43), and major bleeding (OR 1.45, 95% CI 1.17-1.80); no significant differences in outcomes were observed according to BB use in AF patients with COPD.

CONCLUSION

COPD is common in AF, being found in 13% of patients, and is associated with increased burden of comorbidities, differential management, and worse outcomes, with more than a two-fold higher risk of all-cause death and increased risk of CV death and major bleeding. Therapy with BBs does not increase the risk of adverse outcomes in patients with AF and COPD.

An Analysis of Pharmacogenomic-Guided Pathways and Their Effect on Medication Changes and Hospital Admissions: A Systematic Review and Meta-Analysis

Ninety-five percent of the population are estimated to carry at least one genetic variant that is discordant with at least one medication. Pharmacogenomic (PGx) testing has the potential to identify patients with genetic variants that puts them at risk of adverse drug reactions and sub-optimal therapy. Predicting a patient's response to medications could support the safe management of medications and reduce hospitalization. These benefits can only be realized if prescribing clinicians make the medication changes prompted by PGx test results. This review examines the current evidence on the impact PGx testing has on hospital admissions and whether it prompts medication changes. A systematic search was performed in three databases (Medline, CINAHL and EMBASE) to search all the relevant studies published up to the year 2020, comparing hospitalization rates and medication changes amongst PGx tested patients with patients receiving treatment-as-usual (TAU). Data extracted from full texts were narratively synthesized using a process model developed from the included studies, to derive themes associated to a suggested workflow for PGx-guided care and its expected benefit for medications optimization and hospitalization. A meta-analysis was undertaken on all the studies that report the number of PGx tested patients that had medication change(s) and the number of PGx tested patients that were hospitalized, compared to participants that received TAU. The search strategy identified 5 hospitalization themed studies and 5 medication change themed studies for analysis. The meta-analysis showed that medication changes occurred significantly more frequently in the PGx tested arm across 4 of 5 studies. Meta-analysis showed that all-cause hospitalization occurred significantly less frequently in the PGx tested arm than the TAU. The results show proof of concept for the use of PGx in prescribing that produces patient benefit. However, the review also highlights the opportunities and evidence gaps that are important when considering the introduction of PGx into health systems; namely patient involvement in PGx prescribing decisions, thus a better understanding of the perspective of patients and prescribers. We highlight the opportunities and evidence gaps that are important when considering the introduction of PGx into health systems.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

OBJECTIVES

To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

SEARCH METHODS

We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

MAIN RESULTS

Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

AUTHORS' CONCLUSIONS

Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

Medication decision-making and adherence in lupus: Patient-physician discordance and the impact of previous 'Adverse Medical Experiences'

Objectives

Medication adherence is critical in the successful management of lupus. There is very limited existing literature on reasons why non-adherence is not reported. This study explores the impact of current and previous medical experiences on patient satisfaction, adherence and reporting of non-adherence.

Methods

Mixed methodology involved thematic analysis of in-depth interviews (n = 23) to further explore the statistically analysed quantitative survey findings (n = 186).

Results

This study identified five themes: (i) physician-patient discordance and a ‘hierarchy of evidence’ in medication decisions; (ii) the association of adherence with satisfaction with care; (iii) the persisting impact of past adverse medical experiences (AMEs); (iv) the dynamic balance of patient-physician control; and (v) holistic care, beyond a purely medication-based focus. Improving quality of life (43% of participants) and a supportive medical relationship (24%) were the main reasons for adherence. Patient-priorities and self-reported symptoms were perceived as less important to physicians than organ-protection and blood results. Non-reporters of non-adherence, non-adherers and those with past AMEs (e.g. psychosomatic misdiagnoses) had statistically significant lower satisfaction with care. The importance of listening to patients was a key component of every theme, and associated with patient satisfaction and adherence. The mean rating for rheumatologist’s listening skills was 2.88 for non-adherers compared with 3.53 for other participants (mean difference 0.65, P = 0.003).

Conclusion

Patients would like more weight and discussion given to self-reported symptoms and quality of life in medication decisions. Greater understanding and interventions are required to alleviate the persisting impact of past AMEs on some patients’ wellbeing, behaviour and current medical relationships.

The clinical impact of adherence to therapy in airways disease

For a physician, the final step of a consultation consists of developing a treatment plan and prescription. For the patient, this is the start of a process. First, their role in the treatment plan must be clarified, then they may have to obtain an alternative prescription from their general practitioner. Next, they must have the prescription filled and dispensed from the pharmacy and, finally, they must take the treatment on time and for the required duration. For people with chronic conditions, this requires repeatedly returning to the pharmacy for the prescription to be renewed and dispensed. Given that many patients are on multiple treatment regimens and may have poor health literacy, this becomes a complex process and it is not surprising that this can, and frequently does, go wrong.

Research shows that when a patient does not adhere to standard asthma or COPD treatment, they report poor control and overuse of rescue β-agonists, experience frequent exacerbations and are often prescribed add-on treatments such as biological agents. In short, poor treatment adherence can manifest in the same way as a refractory condition.

These clinical features should prompt a clinician to investigate poor adherence as they might investigate a new blood or radiological finding. Examining a patient's prescription refill records or a digitally enabled inhaler can demonstrate a number of patterns of inhaler use. A small minority regularly use their treatment as prescribed but many appear to be “cluster users”: a group of patients who use their treatment correctly when they are unwell, but once some level of personal control is attained, they cease or reduce their use. Others may cease using their treatment because they are not perceiving a benefit or because an alternative condition accounts for their symptoms. In other words, clinicians can consider that treatment adherence is like a clinical sign: something to be investigated so that they may understand the patient's condition better.

Suspected poor treatment adherence should be treated as a clinical sign. It should be suspected among patients with asthma and COPD who have excessive reliever use or recurrent exacerbations. It can be detected using pharmacy data or electronic devices.https://bit.ly/3oqwS5L

Polypharmacy and the Progression of Chronic Kidney Disease: Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease

INTRODUCTION

The renal hazard of polypharmacy has never been evaluated in predialysis chronic kidney disease (CKD) patients.

OBJECTIVE

We aimed to analyze the renal hazard of polypharmacy in predialysis CKD patients with stage 1-5.

METHOD

The data of 2,238 patients from a large-scale multicenter prospective Korean study (2011-2016), excluding 325 patients with various missing data, were reviewed. Polypharmacy was defined as taking 6 or more medications at the time of enrollment; renal events were defined as a ≥50% decrease in kidney function from baseline values, doubling of the serum creatinine levels, or initiation of renal replacement treatment. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using Cox proportional-hazard regression analysis.

RESULTS

Of the 1,913 patients, the mean estimated glomerular filtration rate was 53.6 mL/min/1.73 m2. The mean medication count was 4.1, and the prevalence of polypharmacy was 27.1%. During the average period of 3.6 years, 520 patients developed renal events (27.2%). Although increased medication counts were associated with increased renal hazard with HR (95% CI) of 1.056 (1.007-1.107, p = 0.025), even after adjusting for various confounders, adding comorbidity score and kidney function nullified the statistical significance. In mediation analysis, 55.6% (p = 0.016) of renal hazard in increased medication counts was mediated by the kidney function, and there was no direct effect of medication counts on renal event development. In subgroup analysis, the renal hazard of the medication counts was evident only in stage 1-3 of CKD patients (p for interaction = 0.014).

CONCLUSIONS

We cannot identify the direct renal hazard of multiple medications, and most of the potential renal hazard was derived from intimate relationship with disease burden and kidney function.

Towards Rational Prescription of Common Inhaler Medication in the Multimorbid COPD Patient

COPD is a chronic disease, typically accompanied by multiple comorbid conditions. The need to apply several, and sometimes conflicting, disease-specific treatment guidelines, complicates the management of individual patients. Moreover, national and international recommendations evolve rapidly but provide limited guidance on the integrated approach in the multimorbid patient. Particularly bothersome is the fact that the presence of comorbidities may deteriorate the course of COPD, and inversely COPD may affect the outcome of the comorbid diseases. In addition, some effects of commonly prescribed COPD inhaler medications, including beta2-agonists, long-acting antimuscarinics and especially inhaled corticosteroids, mimic or worsen COPD-related comorbidities. Therefore, the authors combined their perspectives to formulate advice that may help physicians to improve COPD patient care in daily practice when comorbidities are present. Diabetes, atrial fibrillation, osteoporosis/fractures, infections (pneumonia and tuberculosis) and asthma were identified as areas where practicing clinicians should give special attention to the risk-benefit ratio of the inhaled medication. Overall, the presence of multimorbidity in a COPD patient should act as a signal to carefully reconsider the treatment choices.

Short physical performance battery as a practical tool to assess mortality risk in chronic obstructive pulmonary disease

RATIONALE

chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and common in older adults. The BODE Index is the most recognised mortality risk score in COPD but includes a 6-minute walk test (6MWT) that is seldom available in practise; the BODE Index may be better adopted if the 6MWT was replaced.

OBJECTIVES

we investigated whether a modified BODE Index in which 6MWT was replaced by an alternative measure of physical capacity, specifically the short physical performance battery (SPPB) or components, retained its predictive ability for mortality in individuals with COPD.

METHODS

we analysed 630 COPD patients from the ERICA cohort study for whom UK Office for National Statistics verified mortality data were available. Variables tested at baseline included spirometry, 6MWT, SPPB and its components (4-m gait speed test [4MGS], chair stand and balance). Predictive models were developed using stratified multivariable Cox regression, and assessed by C-indices and calibration plots with 10-fold cross-validation and replication.

RESULTS

during median 2 years of follow-up, 60 (10%) individuals died. There was no significant difference between the discriminative ability of BODE6MWT (C-index 0.709, 95% confidence interval [CI], 0.680-0.737), BODESPPB (C-index 0.683, 95% CI, 0.647-0.712), BODE4MGS (C-index 0.676, 95% CI, 0.643-0.700) and BODEBALANCE (C-index 0.686, 95% CI, 0.651-0.713) for predicting mortality.

CONCLUSIONS

the SPPB, and its 4MGS and balance components, can potentially be used as an alternative to the 6MWT in the BODE Index without significant loss of predictive ability in all-cause mortality.

Changes in Multimorbidity and Polypharmacy Patterns in Young and Adult Population over a 4-Year Period: A 2011-2015 Comparison Using Real-World Data

The pressing problem of multimorbidity and polypharmacy is aggravated by the lack of specific care models for this population. We aimed to investigate the evolution of multimorbidity and polypharmacy patterns in a given population over a 4-year period (2011–2015). A cross-sectional, observational study among the EpiChron Cohort, including anonymized demographic, clinical and drug dispensation information of all users of the public health system ≥65 years in Aragon (Spain), was performed. An exploratory factor analysis, stratified by age and sex, using an open cohort was carried out based on the tetra-choric correlations among chronic diseases and dispensed drugs during 2011 and compared with 2015. Seven baseline patterns were identified during 2011 named as: mental health, respiratory, allergic, mechanical pain, cardiometabolic, osteometabolic, and allergic/derma. Of the epidemiological patterns identified in 2015, six were already present in 2011 but a new allergic/derma one appeared. Patterns identified in 2011 were more complex in terms of both disease and drugs. Results confirmed the existing association between age and clinical complexity. The systematic associations between diseases and drugs remain similar regarding their clinical nature over time, helping in early identification of potential interactions in multimorbid patients with a high risk of negative health outcomes due to polypharmacy.

Drug metabolism in severe chronic obstructive pulmonary disease: A phenotyping cocktail study

AIMS

To evaluate the effect of severe chronic obstructive pulmonary disease (COPD) on drug metabolism by comparing the pharmacokinetics of patients with severe COPD with healthy volunteers and using the modified Inje drug cocktail.

METHODS

This was a single-centre pharmacokinetic study with 12 healthy participants and 7 participants with GOLD D COPD. Midazolam 1 mg, dextromethorphan 30 mg, losartan 25 mg, omeprazole 20 mg, caffeine 130 mg and paracetamol 1000 mg were simultaneously administered and intensive pharmacokinetic sampling was conducted over 8 hours. Drug metabolism by CYP3A4, CYP2D6, CYP2C9, CYP2C19, CYP1A2, UGT1A6 and UGT1A9 in participants with COPD were compared with phenotypes in healthy controls.

RESULTS

The oral clearance (95% confidence interval) in participants with COPD relative to controls was: midazolam 63% (60-67%); dextromethorphan 72% (40-103%); losartan 53% (52-55%); omeprazole 35% (31-39%); caffeine 52% (50-53%); and paracetamol 73% (72-74%). There was a 5-fold increase in AUC for omeprazole and approximately 2-fold increases for caffeine, losartan, dextromethorphan, and midazolam. The AUC of paracetamol, which is mostly glucuronidated, was increased by about 60%.

CONCLUSION

Severe COPD is associated with a clinically significant reduction in oral drug clearance. This may be greater for cytochrome P450 substrates than for glucuronidated drugs. This supports reduced starting doses when prescribing for patients with severe COPD.

Hospitalization increases while economic status deteriorates in late stages of chronic obstructive pulmonary disease: the Korean National Health and Nutrition Examination Survey for 2007-2015

Background

Chronic obstructive pulmonary disease (COPD) is associated with frequent hospitalizations, higher mortality, and healthcare costs. Low-income COPD patients have higher rates of emergency department visits and hospitalization due to COPD exacerbation. However, other causes of admissions and their economic burden have not been well-elucidated.

Methods

We analyzed the Korean National Health and Nutrition Examination Survey (KNHANES) dataset for 2007-2015. The diagnosis and staging of COPD were based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.

Results

Among the 97,622 participants in KNHANES for 2007-2015, we selected 33,963 participants (4,430 with and 29,533 without COPD) aged ≥40 years, who underwent spirometry, and provided the admission history for the previous year. Participants with COPD had a higher admission rate than those without COPD (12.8% vs. 10.4%, P<0.001). The admission rate increased as the stage of COPD advanced from GOLD 1 to GOLD 4 for total causes (11.5%, 13.6%, 15.1%, and 25.0%, respectively, P<0.001) and respiratory illnesses (0.5%, 1.3%, 4.6%, and 12.5%, respectively, P<0.001). The proportion of the lowest quartile household income increased in the late stages of COPD (GOLD 1-4; 35.2%, 32.1%, 44.9%, and 70.8%, respectively, P<0.01).

Conclusions

The hospitalization rate increased in advanced COPD, while GOLD stages 3 and 4 were associated with deterioration in economic status.

Frailty Status and Polypharmacy Predict All-Cause Mortality in Community Dwelling Older Adults in Europe

European population ageing is associated with frailty, a complex geriatric syndrome, and polypharmacy, both resulting in adverse health outcomes. In this study we aimed to evaluate the impact of frailty and polypharmacy, on mortality rates, within 30 months, using a cohort of SHARE participants aged 65 years old or more. Frailty was assessed using a version of Fried’s phenotype criteria operationalized to SHARE while polypharmacy was defined as taking five or more drugs per day. We found a prevalence of 40.4% non-frail, 47.3% pre-frail and 12.3% frail participants. Moreover, a prevalence of polypharmacy of 31.3% was observed, being 3 three times more prevalent in frail individuals and two times in pre-frail individuals, when compared with non-frail. Individuals with both conditions had shown higher mortality rates. Comparing with non-polymedicated non-frail individuals all the other conditions are more prone to die within 30 months. Polymedicated older and male participants exhibited also higher mortality rates. This work shows polypharmacy and frailty to be associated with a higher risk of all-cause of mortality and highlights the need to decrease ‘unnecessary’ polypharmacy to reduce drug-related issues and also the need to assess frailty early to prevent avoidable adverse outcomes.

COPD Management in Community Pharmacy Results in Improved Inhaler Use, Immunization Rate, COPD Action Plan Ownership, COPD Knowledge, and Reductions in Exacerbation Rates

Purpose

To evaluate the effectiveness of a pilot community pharmacy care model for patients with chronic obstructive pulmonary disease (COPD) to improve: 1) inhaler technique; 2) medication adherence; and 3) uptake of non-pharmacological treatment and prevention activities.

Patients and Methods

Forty "host" pharmacies in Sydney were invited to recruit eligible patients and to provide a counselling room/area in their pharmacy for service provision. Eligible patients were referred to two "consultant" pharmacists, specifically trained to deliver a specialized pharmacy COPD service which involved 3 in-pharmacy visits and 2 follow-up phone calls over a 6-month period. The service consisted of 1) inhaler technique assessment; 2) medication adherence assessment; and 3) referrals to the patient's general practitioner (GP) to facilitate the uptake of non-pharmacological resources as well as to review COPD medications/devices, as required. Pre-post analyses were conducted using paired Student's t-test and Wilcoxon Signed Rank Test for independent variables and chi-squared tests for proportional data.

Results

Nine "host" pharmacies recruited 40 patients, of whom 37 completed the baseline Visit and 27 completed all Visits. A total of 270 interventions were provided by the "consultant" pharmacists with most provided at Visit 1 (176). The most common interventions were addressing patient gaps in COPD knowledge and inhaler technique. A total of 119 referrals were made to GPs for various reasons, the most common being for a COPD action plan, pulmonary rehabilitation, or pneumonia vaccination. There were significant improvements pre-post intervention in inhaler use competence, COPD knowledge, immunization rate for pneumonia, exacerbation rate and COPD plan ownership.

Conclusion

In this pilot study, the specialized pharmacy-based COPD care model delivered by "consultant" pharmacists in community pharmacies provided significant health benefits for patients. Further research is needed to assess the model's effectiveness in a larger population as well as when measured against standard care.

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population - Public Health Implications

COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient’s caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.

Are payment methods for prescription drugs associated with polypharmacy in older adults in Ireland? Evidence from the TILDA cohort study

OBJECTIVES

Polypharmacy is commonly defined as the use of five or more medications, is associated with a range of adverse outcomes and is particularly common in older adults. We sought to examine the relationship between polypharmacy and payment methods for prescription drugs among older adults in Ireland.

METHODS

This is a cross-sectional analysis of data from wave 3 of The Irish Longitudinal Study on Aging, a nationally representative cohort study sample of community-living adults aged 50 years and older in Ireland. We used multivariable logistic regression to model the independent relationship between polypharmacy and drug payment methods. We controlled for a wide range of demographic, socioeconomic and health-related variables.

RESULTS

Enrolment in publicly funded schemes which entitle participants to subsidised or free prescription medications was independently associated with increased odds of reporting polypharmacy. Relative to out-of-pocket payment, we found polypharmacy was independently associated with payment via medical card (OR 2.65; 95% CI 2.13 to 3.28), drugs payment scheme (OR 3.83; 95% CI 2.96 to 4.95), long-term illness scheme (OR 4.24; 95% CI 3.06 to 5.87), but not private health insurance (OR 0.82; 95% CI 0.42 to 1.62).

CONCLUSIONS

Given multiple payment methods available for funding prescription charges in Ireland, there is a significant differential in the upfront costs faced by patients. One implication of our results is that the quantity of medications consumed by an individual may be influenced by payment methods for prescription fees. This could lead to overconsumption of medicines by those who are covered, or underconsumption by those who are not. However, our study was limited by an inability to discriminate between appropriate and inappropriate polypharmacy or to account for differential levels of multimorbidity, suggesting further research on this topic is warranted.

Integrating Comorbidities and Phenotype-Based Medicine in Patient-Centered Medicine in COPD

Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy.

Irritable bowel syndrome increases the risk of chronic obstructive pulmonary disease: A retrospective cohort study

Both inflammation and infection are associated with the development of irritable bowel syndrome (IBS) and chronic obstructive pulmonary disease (COPD). The purpose of this study is to further elucidate the association between IBS and COPD through a retrospective cohort study. We enrolled IBS patients diagnosed between 2000 and 2011 with follow-up for at least one year. The non-IBS patients as comparison group were selected with 1:3 matching by propensity score. Statistical analysis was utilized to assess the differences in characteristic distribution, and to compare the cumulative incidence of COPD between the IBS and non-IBS cohorts. We selected 14,021 IBS patients and 42,068 non-IBS patients for comparison. The IBS patients exhibited a significant risk to develop COPD compared with non-IBS patients. Additionally, the cumulative incidence rate of COPD in the IBS cohort increased significantly during the follow-up period of more than ten years, compared to the non-IBS cohort, based on the Kaplan-Meier analysis. The risk of COPD was also significantly decreased in those patients with more than eighteen IBS-related clinical visits. This retrospective cohort study demonstrates the significantly increased risk of COPD in patients with IBS. Therefore, early inspection and prevention of COPD is essential for patients with IBS.

The predictors of and reasons for non-adherence in an observational cohort of patients with rheumatoid arthritis commencing methotrexate

OBJECTIVE

In order to develop interventions to optimize MTX use for the treatment of RA we evaluated the rate of, reasons for and predictors of MTX non-adherence during the first 6 months of therapy.

METHODS

The Rheumatoid Arthritis Medication Study (RAMS) is a prospective multicentre cohort study of incident MTX users in the UK. Prior to MTX commencement demographic, clinical and psychological data were collected. A weekly patient-completed diary recorded MTX dose, possible side effects and adherence over 26 weeks. The number of non-adherent weeks was calculated. Potential baseline predictors of ever non-adherence (⩾1 week non-adherent) during the first 6 months of MTX therapy were identified using logistic regression analyses.

RESULTS

606 patients with RA were included; 69% female, mean (s.d.) age 60 (13) years and DAS28 score 4.2 (1.2). Over the first 6 months following MTX initiation, 158 (26%) patients were ever non-adherent (71% intentional, 19% non-intentional, 10% unexplained) and mean (s.d.) number of non-adherent weeks was 2.5 (2.1). Multivariable predictors of ever non-adherence included DAS28 [odds ratios (OR) 1.1, 95% CI 1.0, 1.4], fatigue (OR 1.1, 95% CI 1.0, 1.2 per cm), ⩾2 comorbidities vs no comorbidities (OR 1.9, 95% CI 1.1, 3.5) and high medication concerns despite perceived need (OR 1.1, 95% CI 1.0, 1.1 per unit decrease in need/concern differential).

CONCLUSION

This is the largest study evaluating early intentional and non-intentional non-adherence to MTX, which has identified that patient beliefs and multi-morbidity strongly link with non-adherence. These findings can direct the design of and provide potential targets for interventions to improve patient adherence.

Screening for comorbidities in COPD

Due to growing recognition of comorbidities, COPD is no longer considered a disease affecting only the respiratory system. Its management now entails the early diagnosis and treatment of comorbidities. However, although many studies have examined the impact of comorbidities on the evolution of COPD and patients' quality of life, very few have explored the means to systematically identify and manage them. The aims of this article are to summarise the state of current knowledge about comorbidities associated with COPD and to propose a possible screening protocol in the outpatient setting, emphasising the areas needing further research.

Association of Opioid and Benzodiazepine Use with Adverse Respiratory Events in Older Adults with Chronic Obstructive Pulmonary Disease

Rationale: Older adults with chronic obstructive pulmonary disease (COPD) are at substantially increased risk for medication-related adverse events. Two frequently prescribed classes of drugs that pose a particular risk to this patient group are opioids and benzodiazepines. Research on this topic has yielded conflicting findings.Objectives: The purpose of this study was to examine, among older adults with COPD, whether: 1) independent or concurrent use of opioid and benzodiazepine medications was associated with hospitalizations for respiratory events, and 2) this association was exacerbated by the presence of obstructive sleep apnea (OSA).Methods: We conducted a case-control study of Medicare beneficiaries aged ≥66 years, who were diagnosed with COPD in 2013, using the 5% national Medicare database. Cases (n = 3,232) were defined as patients hospitalized for a primary COPD-related respiratory diagnosis in 2014 and were matched with up to two control subjects (n = 6,247) on index date, age, sex, socioeconomic status, comorbidity, presence of OSA, COPD medication, and COPD complexity.Results: In comparison to the referent (no opioid or benzodiazepine use), opioid use alone (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.52-1.97), benzodiazepine use alone (aOR, 1.42; 95% CI, 1.21-1.66), and concurrent opioid/ benzodiazepine use (aOR, 2.32; 95% CI, 1.94-2.77) in the 30 days before the event/index date were all associated with an increased risk of hospitalization for a respiratory condition. Risk of hospitalization was higher with concurrent opioid and benzodiazepine use when compared with use of either medication alone. There was no statistically significant interaction between OSA and either of the drugs, alone or in combination. However, the adverse respiratory effects of concurrent opioid and benzodiazepine use were increased in patients with a high degree of COPD complexity. All of the above findings persisted using exposure windows that extended to 60 and 90 days before the event/index date.Conclusions: Among older adults with COPD, use of opioid and benzodiazepine medications alone or in combination were associated with increased adverse respiratory events. The adverse effects of these medications were not exacerbated in patients with COPD-OSA overlap syndrome. However, the adverse impact of dual opioid and benzodiazepine was greater in patients with high-complexity COPD.

Polypharmacy among Older Individuals with COPD: Trends between 2000 and 2015 in Quebec, Canada

The treatment of chronic obstructive pulmonary disease (COPD) and concomitant diseases requires several medications. Yet there is little data on how the pharmacological burden progressed over time among older individuals with COPD. We aimed to: 1) describe the proportion of older adults with COPD in Quebec, Canada, that were exposed to polypharmacy (≥10, ≥15 or ≥20 medications/year) between 2000 and 2015; 2) calculate the proportion of individuals receiving specific prescriptions for COPD during this period. We conducted a population-based cohort study with the Quebec Integrated Chronic Disease Surveillance System. Individuals aged ≥66 years with COPD and covered by the universal public drug plan were included. We calculated the total number of drugs used at least once by each individual during each of the studied years, and used age-standardized proportions to compare proportions of users between the years. The average number of drugs used increased from 12.0 in 2000 to 14.8 in 2015. The proportion of individuals exposed to polypharmacy increased (≥10 drugs: 62.0% to 74.6%;≥15 drugs: 31.2% to 45.4%; ≥20 drugs: 12.3% to 22.4%). The proportion of individuals receiving long-acting bronchodilators increased from 18.7% in 2000 to 69.6% in 2015. The use of short-acting bronchodilators decreased from 81.5% to 67.9%, and that of inhaled corticosteroids from 60.6% to 26.0%. The proportion of users of methylxanthines decreased from 15.0% to 1.9%. Older individuals with COPD are increasingly exposed to polypharmacy. Identifying which polypharmacy is beneficial is a priority.

Holistic care program for elderly patients to integrate spiritual needs, social activity, and self-care into disease management in primary care (HoPES3): study protocol for a cluster-randomized trial

BACKGROUND

Strategies to improve the care of elderly, multimorbid patients frequently focus on implementing evidence-based knowledge by structured assessments and standardization of care. In Germany, disease management programs (DMPs), for example, are run by general practitioners (GPs) for this purpose. While the importance of such measures is undeniable, there is a risk of ignoring other dimensions of care which are essential, especially for elderly patients: their spiritual needs and personal resources, loneliness and social integration, and self-care (i.e., the ability of patients to do something on their own except taking medications to increase their well-being). The aim of this study is to explore whether combining DMPs with interventions to address these dimensions is feasible and has any impact on relevant outcomes in elderly patients with polypharmacy.

METHODS

An explorative, cluster-randomized controlled trial with general practices as the unit of randomization will be conducted and accompanied by a process evaluation. Patients aged 70 years or older with at least three chronic conditions receiving at least three medications participating in at least one DMP will be included. The control group will receive DMP as usual. In the intervention group, GPs will conduct a spiritual needs assessment during the routinely planned DMP appointments and explore whether the patient has a need for more social contact or self-care. To enable GPs to react to such needs, several aids will be provided by the study: a) training of GPs in spiritual needs assessment and training of medical assistants in patient counseling regarding self-care and social activity; b) access to a summary of regional social offers for seniors; and c) information leaflets on nonpharmacological interventions (e.g., home remedies) to be applied by patients themselves to reduce frequent symptoms in old age. The primary outcome is health-related self-efficacy (using the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES-6G)). Secondary outcomes are general self-efficacy (using the General Self-Efficacy Scale (GSES)), physical and mental health (using the Short-Form Health Survey (SF-12)), patient activation (using the Patient Activation Measure (PAM)), medication adherence (using the Medication Adherence Report Scale (MARS)), beliefs in medicine (using the Beliefs About Medicines Questionnaire (BMQ)), satisfaction with GP care (using selected items of the European Project on Patient Evaluation of General Practice (EUROPEP)), social contacts (using the 6-item Lubben Social Network Scale (LSNS-6)), and loneliness (using the 11-item De-Jong-Gierveld Loneliness Scale (DJGS-11)). Interviews will be conducted to assess the mechanisms, feasibility, and acceptability of the interventions.

DISCUSSION

If the interventions prove to be effective and feasible, large-scale implementation should be sought and evaluated by a confirmatory design.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00015696 . Registered on 22 January 2019.

Quantification of inaccurate diagnosis of COPD in primary care medicine: an analysis of the COACH clinical audit

Background: Inaccurate diagnosis in COPD is a current problem with relevant consequences in terms of inefficient health care, which has not been thoroughly studied in primary care medicine. The aim of the present study was to evaluate the degree of inaccurate diagnosis in Primary Care in Spain and study the determinants associated with it. Methods: The Community Assessment of COPD Health Care (COACH) study is a national, observational, randomized, non-interventional, national clinical audit aimed at evaluating clinical practice for patients with COPD in primary care medicine in Spain. For the present analysis, a correct diagnosis was evaluated based on previous exposure and airway obstruction with and without the presence of symptoms. The association of patient-level and center-level variables with inaccurate diagnosis was studied using multivariate multilevel binomial logistic regression models. Results: During the study 4,307 cases from 63 centers were audited. The rate of inaccurate diagnosis was 82.4% (inter-regional range from 76.8% to 90.2%). Patient-related interventions associated with inaccurate diagnosis were related to active smoking, lung function evaluation, and specific therapeutic interventions. Center-level variables related to the availability of certain complementary tests and different aspects of the resources available were also associated with an inaccurate diagnosis. Conclusions: The prevalence data for the inaccurate diagnosis of COPD in primary care medicine in Spain establishes a point of reference in the clinical management of COPD. The descriptors of the variables associated with this inaccurate diagnosis can be used to identify cases and centers in which inaccurate diagnosis is occurring considerably, thus allowing for improvement.

Reduction in exacerbation of COPD in patients of advanced age using the Japanese Kampo medicine Dai-kenchu-to: a retrospective cohort study

Purpose

Patients with symptomatic COPD are recommended to use inhaled bronchodilators containing long-acting muscarinic receptor antagonists (LAMAs). However, bronchodilators may cause gastrointestinal adverse effects due to anticholinergic reactions, especially in advanced-age patients with COPD. Dai-kenchu-to (TU-100, Da Jian Zhong Tang in Chinese) is the most frequently prescribed Japanese herbal Kampo medicine and is often prescribed to control abdominal bloating and constipation. The purpose of this study was to evaluate the role of Dai-kenchu-to as a supportive therapy in advanced-age patients with COPD.

Patients and methods

We used the Japanese Diagnosis Procedure Combination inpatient database and identified patients aged ≥75 years who were hospitalized for COPD exacerbation. We then compared the risk of re-hospitalization for COPD exacerbation or death between patients with and without Dai-kenchu-to using 1-to-4 propensity score matching. A Cox proportional hazards model was used to compare the two groups. We performed subgroup analyses for patients with and without LAMA therapy.

Results

Patients treated with Dai-kenchu-to had a significantly lower risk of re-hospitalization or death after discharge; the HR was 0.82 (95% CI, 0.67–0.99) in 1-to-4 propensity score matching. Subgroup analysis of LAMA users showed a significant difference in re-hospitalization or death, while subgroup analysis of LAMA non-users showed no significant difference.

Conclusion

Our findings indicate that Dai-kenchu-to may have improved the tolerability of LAMA in advanced-age patients with COPD and, therefore, reduced the risk of re-hospitalization or death from COPD exacerbation. Dai-kenchu-to may be recommended as a useful supportive therapy for advanced-age patients with COPD.