Trends in prescriptions and costs of inhaled medications in chronic obstructive pulmonary disease: a 19-year population-based study from Canada

Budget impact analysis of adopting primary care-based case detection of chronic obstructive pulmonary disease in the Canadian general population

BACKGROUND

An estimated 70% of Canadians with chronic obstructive pulmonary disease (COPD) have not received a diagnosis, creating a barrier to early intervention, and there is growing interest in the value of primary care-based opportunistic case detection for COPD. We sought to build on a previous cost-effectiveness analysis by evaluating the budget impact of adopting COPD case detection in the Canadian general population.

METHODS

We used a validated discrete-event microsimulation model of COPD in the Canadian general population aged 40 years and older to assess the costs of implementing 8 primary care-based case detection strategies over 5 years (2022-2026) from the health care payer perspective. Strategies varied in eligibility criteria (based on age, symptoms or smoking history) and testing technology (COPD Diagnostic Questionnaire [CDQ] or screening spirometry). Costs were determined from Canadian studies and converted to 2021 Canadian dollars. Key parameters were varied in one-way sensitivity analysis.

RESULTS

All strategies resulted in higher total costs compared with routine diagnosis. The most cost-effective scenario (the CDQ for all patients) had an associated total budget expansion of $423 million, with administering case detection and subsequent diagnostic spirometry accounting for 86% of costs. This strategy increased the proportion of individuals diagnosed with COPD from 30.4% to 37.8%, and resulted in 4.6 million referrals to diagnostic spirometry. Results were most sensitive to uptake in primary care.

INTERPRETATION

Adopting a national COPD case detection program would be an effective method for increasing diagnosis of COPD, dependent on successful uptake. However, it will require prioritisation by budget holders and substantial additional investment to improve access to diagnostic spirometry.

Trends in hospital admissions for chronic obstructive pulmonary disease over 16 years in Canada

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an ambulatory care-sensitive condition, and the rate of hospital admissions for COPD is an indicator of the quality of outpatient care. We sought to determine long-term trends in hospital admissions for COPD in Canada.

METHODS

Using a comprehensive national database of hospital admissions in Canada, we identified those with a main discharge diagnosis of COPD for patients aged 40 years and older between 2002 and 2017. We calculated sex-specific, age-standardized trends in annual rates of hospital admissions for COPD separately for younger (40-64 yr) and older adults (≥ 65 yr). We used spline regression to examine changes in the admissions trends for each sex and age group.

RESULTS

Over 16 years, 1 134 359 hospital admissions were for COPD. Between 2002 and 2017, the total number of admissions increased by 68.8%, from 52 937 to 89 384. The overall crude admission rate increased by 30.0%, from 368 to 479 per 100 000 population, and the sex-and age-standardized admission rate increased by 9.6%, from 437 to 479 per 100 000 population. Age-standardized rates increased by 12.2% among younger females, by 24.4% among younger males and by 29.8% among older females, but decreased by 9.0% among older males. Over the same period, the all-cause sex-and age-standardized admission rate declined by 23.0%.

INTERPRETATION

Hospital admissions for COPD have increased since 2010, even after adjusting for population growth and aging, and despite declining rates of all-cause hospital admissions. The secular increase in COPD admissions indicates that the burden of COPD on Canadian health care systems is increasing.

High use of short-acting β2-agonists in COPD is associated with an increased risk of exacerbations and mortality

Background

Short-acting β₂-agonist (SABA) overuse has been associated with an increased risk of exacerbations in asthma; however, less is known about SABA use in COPD. Our aim was to describe SABA use and investigate potential associations between high SABA use and the risk of future exacerbations and mortality in COPD.

Methods

This observational study identified COPD patients in primary care medical records in Sweden. Data were linked to the National Patient Registry, the Prescribed Drug Registry and the Cause of Death Registry. The index date was 12 months after the date of COPD diagnosis. During a 12-month prior to index baseline period, information on SABA use was collected. Patients were followed with respect to exacerbations and mortality for 12 months post index.

Results

Of the 19 794 COPD patients included (mean age 69.1 years, 53.3% females), 15.5% and 7.0% had collected ≥3 or ≥6 SABA canisters during the baseline period, respectively. A higher level of SABA use (≥6 canisters) was independently associated with a higher risk of both moderate and severe exacerbations (hazard ratio (HR) 1.28 (95% CI 1.17‒1.40) and 1.76 (95% CI 1.50‒2.06), respectively) during follow-up. In total, 673 (3.4%) patients died during the 12-month follow-up period. An independent association was found between high SABA use and overall mortality (HR 1.60, 95% CI 1.07‒2.39). This association, however, was not found in patients using inhaled corticosteroids as maintenance treatment.

Conclusion

In COPD patients in Sweden, high SABA use is relatively common and associated with a higher risk of exacerbations and all-cause mortality.

Exploring the appropriateness of prescribing practice of inhaled pharmacotherapy among Aboriginal Australians in the Top End Northern Territory of Australia: a retrospective cohort study

BACKGROUND

Aboriginal Australians are reported to have a high burden of chronic airway diseases. However, prescribing patterns and related outcomes of airway directed inhaled pharmacotherapy, (short-acting beta agonists (SABA), short-acting muscarinic antagonists (SAMA), long-acting β-agonists (LABA), long-acting muscarinic antagonists (LAMA) and inhaled corticosteroids (ICS)) among Aboriginal Australian patients with chronic airway disease have been sparsely reported in the past.

METHODS

A retrospective cohort study was conducted, using clinical, spirometry data, chest radiology, primary healthcare (PHC) presentations and hospital admission rates among Aboriginal patients identified to have been prescribed inhaled pharmacotherapy in remote and rural communities referred to the respiratory specialist service in the Top End, Northern Territory of Australia.

RESULTS

Of the 372 identified active patients, 346 (93%) had inhaled pharmacotherapy prescribed (64% female, median age 57.7 years). ICS was the most common prescription (72% of the total cohort) and was recorded to be prescribed in 76% of patients with bronchiectasis, and 80% of patients with asthma or chronic obstructive pulmonary disease (COPD). Fifty-eight percent of patients had a respiratory hospital admission and 57% had a recorded PHC presentation for a respiratory issue during the study period, with a higher rate of hospital admissions among patients prescribed ICS compared with those on SAMA/SABA or LAMA/LABA without ICS (median rate (per person per year) 0.42 vs 0.21 and 0.21 (p=0.004). Regression models demonstrated that presence of COPD or bronchiectasis alongside ICS was associated with significantly increased hospitalisation rates (1.01 admissions/person/year (95% CI 0.15 to 1.87) and 0.71 admissions/person/year (95% CI 0.23 to 1.18) against patients without COPD/bronchiectasis, respectively).

CONCLUSIONS

This study demonstrates that among Aboriginal patients with chronic airway diseases, ICS is the most common inhaled pharmacotherapy prescribed. Although LAMA/LABA and concurrent ICS use may be appropriate among patients with asthma and COPD, the use of ICS may have detrimental effects among those with underlying bronchiectasis either in isolation or concurrent COPD and bronchiectasis, potentially leading to higher hospital admission rates.

IMplementing Predictive Analytics towards efficient COPD Treatments (IMPACT): protocol for a stepped-wedge cluster randomized impact study

INTRODUCTION

Personalized disease management informed by quantitative risk prediction has the potential to improve patient care and outcomes. The integration of risk prediction into clinical workflow should be informed by the experiences and preferences of stakeholders, and the impact of such integration should be evaluated in prospective comparative studies. The objectives of the IMplementing Predictive Analytics towards efficient chronic obstructive pulmonary disease (COPD) treatments (IMPACT) study are to integrate an exacerbation risk prediction tool into routine care and to determine its impact on prescription appropriateness (primary outcome), medication adherence, quality of life, exacerbation rates, and sex and gender disparities in COPD care (secondary outcomes).

METHODS

IMPACT will be conducted in two phases. Phase 1 will include the systematic and user-centered development of two decision support tools: (1) a decision tool for pulmonologists called the ACCEPT decision intervention (ADI), which combines risk prediction from the previously developed Acute COPD Exacerbation Prediction Tool with treatment algorithms recommended by the Canadian Thoracic Society's COPD pharmacotherapy guidelines, and (2) an information pamphlet for COPD patients (patient tool), tailored to their prescribed medication, clinical needs, and lung function. In phase 2, we will conduct a stepped-wedge cluster randomized controlled trial in two outpatient respiratory clinics to evaluate the impact of the decision support tools on quality of care and patient outcomes. Clusters will be practicing pulmonologists (n ≥ 24), who will progressively switch to the intervention over 18 months. At the end of the study, a qualitative process evaluation will be carried out to determine the barriers and enablers of uptake of the tools.

DISCUSSION

The IMPACT study coincides with a planned harmonization of electronic health record systems across tertiary care centers in British Columbia, Canada. The harmonization of these systems combined with IMPACT's implementation-oriented design and partnership with stakeholders will facilitate integration of the tools into routine care, if the results of the proposed study reveal positive association with improvement in the process and outcomes of clinical care. The process evaluation at the end of the trial will inform subsequent design iterations before largescale implementation.

TRIAL REGISTRATION

NCT05309356.

Impact of the use of anti-glaucoma medications on the risk of herpetic keratitis recurrence

PURPOSE

Numerous case reports have associated anti-glaucoma medications with recurrence of herpes simplex virus (HSV) and herpes zoster virus (HZV) keratitis. The aim of our study was to determine whether different anti-glaucoma agents are associated with recurrence of herpetic keratitis.

METHODS

This was a retrospective cohort study using health databases from a Canadian province from January 2001 to December 2012. A new cohort of users on topical prostaglandins (PGs), beta blockers (BBs), alpha-2 agonists (AAs) and carbonic anhydrase inhibitors (CAIs) was created. The date of the third anti-glaucoma drug dispensation within 90 days was deemed the index date of the case. Herpetic keratitis events, as defined by an ICD-9/10 code for HSV or HZV keratitis, or the dispensation of an anti-viral medication by either an ophthalmologist or an optometrist, were examined prior to and following the index date. Risk ratios (RRs) were computed to compare the risk of HSV/HZV keratitis among the PG, BB, AA, and CAI groups individually and collectively while adjusting for age and sex.

RESULTS

Among 19,986 users of glaucoma medications identified, there were 684 cases of HSV/HZV keratitis. There was no increased risk of HSV/HZV keratitis recurrence for any of the four glaucoma medications classes individually or collectively when adjusted for age and sex. There was also no increased risk for redeveloping either HSV keratitis only or HZV keratitis only amongst all anti-glaucoma users.

CONCLUSION

There is no association between the use of topical ocular hypotensive therapies and HSV/HZV keratitis recurrence. Further studies are needed to confirm these findings.

Are younger COPD patients adequately vaccinated for influenza and pneumococcus?

Influenza and pneumococcal pneumonia are major causes of increased morbidity and mortality among elderly and COPD patients. Vaccines against influenza and pneumococcus are recommended for COPD patients according to GOLD 2020 guidelines to prevent serious illnesses. Despite their high morbidity and mortality burden, the vaccination coverage rates remain far below the WHO's recommended targets. In Greece, there are insufficient data on influenza and pneumococcal immunization rates among younger COPD patients. This study investigated whether COPD patients under the age of 65 are adequately vaccinated against influenza and pneumococcus and the factors that influence vaccination rates. 1100 individuals at 22 Primary Health Centers in Central Greece participated in a two-year spirometry monitoring program. Face-to-face interviews were used to collect information regarding demographics, smoking status, comorbidities, respiratory illnesses in the previous two years, and influenza and pneumococcal vaccination coverage from all COPD patients. 117 patients aged 40-65 years old were diagnosed with COPD and 80.3% were males. Only 40.2% of them had received influenza and 32.5% pneumococcus vaccinations. Age, advanced stage of COPD, years on COPD diagnosis, respiratory infection within the previous two years, comorbidity, and smoking cessation are all positively connected with influenza and pneumococcus vaccine coverage in younger COPD patients. Gender, education level, and marital status did not affect influenza and pneumococcus vaccination rates. These vaccination rates among younger COPD patients demonstrate the need for increased awareness and knowledge about the advantages of immunizations in lowering morbidity and mortality.

Prescription Pathways from Initial Medication Use to Triple Therapy in Older COPD Patients: A Real-World Population Study

BACKGROUND AND OBJECTIVE

Triple therapy with an inhaled corticosteroid (ICS), a long-acting β₂-agonist bronchodilator (LABA) and a long-acting muscarinic antagonist (LAMA) is recommended as step-up therapy for chronic obstructive pulmonary disease (COPD) patients who continue to have persistent symptoms and increased risk of exacerbation despite treatment with dual therapy. We sought to evaluate different treatment pathways through which COPD patients were escalated to triple therapy.

METHODS

We used population health databases from Ontario, Canada to identify individuals aged 66 or older with COPD who started triple therapy between 2014 and 2017. Median time from diagnosis to triple therapy was estimated using the Kaplan-Meier method. We classified treatment pathways based on treatments received prior to triple therapy and evaluated whether pathways differed by exacerbation history, blood eosinophil counts or time period.

RESULTS

Among 4108 COPD patients initiating triple therapy, only 41.2% had a COPD exacerbation in the year prior. The three most common pathways were triple therapy as initial treatment (32.5%), LAMA to triple therapy (29.8%), and ICS + LABA to triple therapy (15.4%). Median time from diagnosis to triple therapy was 362 days (95% confidence interval:331-393 days) overall, but 14 days (95% CI 12-17 days) in the triple therapy as initial treatment pathway. This pathway was least likely to contain patients with frequent or severe exacerbations (22.0% vs. 31.5%, p < 0.001) or with blood eosinophil counts ≥300 cells/µL (18.9% vs. 22.0%, p < 0.001).

CONCLUSION

Real-world prescription of triple therapy often does not follow COPD guidelines in terms of disease severity and prior treatments attempted.

Escalation Time to Open Triple Combination Therapy from the Initiation of LAMA versus ICS/LABA in COPD Management: Findings from Comparing the Incidence of Tiotropium and ICS/LABA in Real-World Use in South Korea (CITRUS) Study

Background: bronchodilators are the key treatment for chronic obstructive pulmonary disease (COPD), however, inhaled corticosteroids (ICSs)/long-acting β2-agonists (LABA) are widely prescribed. We compared the escalation time to open triple combination therapy between long-acting muscarinic receptor antagonists (LAMA) and ICS/LABA in COPD management. Methods: this retrospective study included COPD patients selected from the National Health Insurance Service of South Korea from January 2005 to April 2015. The primary outcome was the escalation time to triple therapy in patients who initially received LAMA or ICS/LABA. Other outcomes included risk factors predisposing escalation to triple combination therapy. Results: a total of 2444 patients were assigned to the LAMA or ICS/LABA groups. The incidences of triple combination therapy in the LAMA and ICS/LABA groups were 81.0 and 139.8 per 1000 person-years, respectively (p < 0.001); the median times to triple therapy escalation were 281 and 207 days, respectively (p = 0.03). Treatment with ICS/LABA showed a higher risk of triple therapy escalation compared to LAMA (hazard ratio (HR), 1.601; 95% confidence interval (CI), 1.402–1.829). The associated risk factor was male sex. (HR, 1.564; 95% CI, 1.352–1.809). Conclusions: the initiation of COPD treatment with LAMA is associated with a reduced escalation time to triple therapy compared with ICS/LABA.

Prediction of readmission in patients with acute exacerbation of chronic obstructive pulmonary disease within one year after treatment and discharge

Background

To investigate the risk factors and construct a logistic model and an extreme gradient boosting (XGBoost) model to compare the predictive performances for readmission in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients within one year.

Methods

In total, 636 patients with AECOPD were recruited and divided into readmission group (n = 449) and non-readmission group (n = 187). Backward stepwise regression method was used to analyze the risk factors for readmission. Data were divided into training set and testing set at a ratio of 7:3. Variables with statistical significance were included in the logistic model and variables with P < 0.1 were included in the XGBoost model, and receiver operator characteristic (ROC) curves were plotted.

Results

Patients with acute exacerbations within the previous 1 year [odds ratio (OR) = 4.086, 95% confidence interval (CI) 2.723–6.133, P < 0.001), long-acting β agonist (LABA) application (OR = 4.550, 95% CI 1.587–13.042, P = 0.005), inhaled corticosteroids (ICS) application (OR = 0.227, 95% CI 0.076–0.672, P = 0.007), glutamic-pyruvic transaminase (ALT) level (OR = 0.985, 95% CI 0.971–0.999, P = 0.042), and total CAT score (OR = 1.091, 95% CI 1.048–1.136, P < 0.001) were associated with the risk of readmission. The AUC value of the logistic model was 0.743 (95% CI 0.692–0.795) in the training set and 0.699 (95% CI 0.617–0.780) in the testing set. The AUC value of XGBoost model was 0.814 (95% CI 0.812–0.815) in the training set and 0.722 (95% CI 0.720–0.725) in the testing set.

Conclusions

The XGBoost model showed a better predictive value in predicting the risk of readmission within one year in the AECOPD patients than the logistic regression model. The findings of our study might help identify patients with a high risk of readmission within one year and provide timely treatment to prevent the reoccurrence of AECOPD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01692-3.

National Epidemiological Case-Control Study of Pharmacological Smoking Cessation Treatment in Danish Patients with Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that is mainly caused by smoking, and most patients with COPD are either former or current smokers. The optimal way to slow down disease progression and reduce overall mortality is for patients to stop smoking. Patients with COPD are known to have lower socio-economic status and to be more nicotine-dependent than most other smokers and therefore face difficulties when attempting to quit smoking. Pharmacological smoking cessation treatment is known to be the most effective. However, the extent to which this treatment is actually offered to Danish smokers with COPD is unknown.

Aim

The aim of this study was to investigate if patients with COPD were more likely to redeem a prescription for smoking cessation medication compared with matched controls.

Materials and Methods

The study was designed as a registry-based, non-interventional case-control study. All Danish patients with COPD (ICD-10-code J 44 chronic obstructive pulmonary disease) diagnosed between 2009 and 2015 were included (130,797 cases). Controls (252,216) were matched on age, gender and geography. Primary outcome was the number of redeemed prescriptions for smoking cessation medication.

Results

We found that 12% of patients with COPD redeemed a prescription for smoking cessation medication during the eight-year study period. The odds ratio (OR) for redeeming a prescription on smoking cessation medicine was OR 6.22 for patients with COPD compared with their matched controls. We also found that patients with COPD were more likely to redeem smoking cessation medication if they were younger, female or single.

Conclusion

There is substantial room for improvement with respect to pharmacological smoking cessation treatment in Danish patients with COPD. In-depth knowledge of factors contributing to the patients choice of smoking cessation treatment might allow for more personalized guidance of patients with COPD.

Are COPD Prescription Patterns Aligned with Guidelines? Evidence from a Canadian Population-Based Study

BACKGROUND

In contemporary guidelines for the management of Chronic Obstructive Pulmonary Disease (COPD), the history of acute exacerbations plays an important role in the choice of long-term inhaled therapies. This study aimed at evaluating population-level trends of filled inhaled prescriptions over the time course of COPD and their relation to the history of exacerbations.

METHODS

We used administrative health databases in British Columbia, Canada (1997-2015), to create a retrospective incident cohort of individuals with diagnosed COPD. We quantified long-acting inhaled medication prescriptions within each year of follow-up and documented their trend over the time course of COPD. Using generalized linear models, we investigated the association between the frequent exacerbator status (≥2 moderate or ≥1 severe exacerbation(s) in the previous 12 months) and filling a prescription after a physician visit.

RESULTS

132,004 COPD patients were included (mean age 68.6, 49.2% female). The most common medication class during the first year of diagnosis was inhaled corticosteroids (ICS, used by 49.9%), followed by long-acting beta-2 adrenoreceptor agonists (LABA, 31.8%). Long-acting muscarinic receptor antagonists (LAMA) were the least commonly prescribed (10.4%). ICS remained the most common prescription throughout follow-up, being used by approximately 50% of patients during each year. 39.0% of patients received combination inhaled therapies in their first year of diagnosis, with ICS+LABA being the most common (30.7%). The association with exacerbation history was the most pronounced for triple therapy with an odds ratio (OR) of 2.68 for general practitioners and 2.02 for specialists (p<0.001 for both). Such associations were generally stronger among GPs compared with specialists, with the exception of monotherapy with LABA or ICS.

CONCLUSION

We documented low utilization of monotherapies (specifically LAMA) and high utilization of combination therapies (particularly ICS containing). Specialists were less likely to consider exacerbation history in the choice of inhaled therapies compared with GPs.

Cost Effectiveness of Case Detection Strategies for the Early Detection of COPD

OBJECTIVES

The value of early detection and treatment of chronic obstructive pulmonary disease (COPD) is currently unknown. We assessed the cost effectiveness of primary care-based case detection strategies for COPD.

METHODS

A previously validated discrete event simulation model of the general population of COPD patients in Canada was used to assess the cost effectiveness of 16 case detection strategies. In these strategies, eligible patients (based on age, smoking history, or symptoms) received the COPD Diagnostic Questionnaire (CDQ) or screening spirometry, at 3- or 5-year intervals, during routine visits to a primary care physician. Newly diagnosed patients received treatment for smoking cessation and guideline-based inhaler pharmacotherapy. Analyses were conducted over a 20-year time horizon from the healthcare payer perspective. Costs are in 2019 Canadian dollars ($). Key treatment parameters were varied in one-way sensitivity analysis.

RESULTS

Compared to no case detection, all 16 case detection scenarios had an incremental cost-effectiveness ratio (ICER) below $50,000/QALY gained. In the most efficient scenario, all patients aged ≥ 40 years received the CDQ at 3-year intervals. This scenario was associated with an incremental cost of $287 and incremental effectiveness of 0.015 QALYs per eligible patient over the 20-year time horizon, resulting in an ICER of $19,632/QALY compared to no case detection. Results were most sensitive to the impact of treatment on the symptoms of newly diagnosed patients.

CONCLUSIONS

Primary care-based case detection programs for COPD are likely to be cost effective if there is adherence to best-practice recommendations for treatment, which can alleviate symptoms in newly diagnosed patients.

Assessing the uptake, engagement, and safety of a self-management app, COPD.Pal®, for Chronic Obstructive Pulmonary Disease: a pilot study

Chronic Obstructive Pulmonary Disease (COPD) is a widespread condition that accounts for 3 million deaths worldwide annually. Despite being extensive healthcare users, people with COPD (PwCOPD) only spend approximately 1% of their time with a healthcare professional. The rest of the time, they are encouraged to self-manage their condition. To encourage better self-management, Bond Digital Health have created a mobile phone app called COPD.Pal® that helps PwCOPD keep track of their condition. This pilot study aimed to assess the safety, engagement, and early efficacy of the app. 25 PwCOPD were recruited and given COPD.Pal® for 6-weeks. Healthcare usage, self-management knowledge, app engagement, dyspnoea, and health-related quality of life were measured at baseline and at 6-weeks. A feedback questionnaire was also collected at follow-up. T-tests investigated whether differences between the time points were evident in the data. No statistically significant differences were found between the time points for any of the variables measured. Average app engagement was 31.8 days with 84% using COPD.Pal® for 20 or more days during the 6-weeks. 89% of participants stated they would use the app regularly after the study, with 56% stating they’d use it long-term. This study determined that a digital, self-management app would be engaged with and early results indicate that the safety is non-inferior to standard care. Although self-management knowledge remained unaffected by app use, this study provided useful insights regarding how to improve this aspect. This represents one of few studies which involve end-users at an early stage of intervention development, an important strength of the research.

Evaluation of fluticasone propionate/salmeterol for the treatment of COPD: a systematic review

Introduction: Recently, the generic formulation of FP/SAL FDC has been approved in COPD. Although FP/SAL FDC has been the first long-acting FDC approved in COPD, no systematic review assessed the effect of this combination for the treatment of COPD by considering specifically Phase IV studies. The aim of this review was to systematically assess the effect of FP/SAL FDC in COPD patients enrolled in Phase IV studies.Areas covered: The question of this systematic review was to examine the evidence regarding the impact of FP/SAL FDC for the treatment of COPD by searching for Phase IV studies in the ClinicalTrials.gov database.Expert opinion: Generic drugs represent an effective cost-saving step for health-care budgets in the treatment of COPD and should be used in agreement with current recommendations and prescription accuracy. FP/SAL FDC is recommended for the initiation therapy just in a small percentage of symptomatic patients that are at high risk of exacerbation with blood eosinophil counts ≥300 cells per μl. At follow-up, FP/SAL FDC can be escalated to triple ICS/LABA/LAMA combination or switched to LABA/LAMA combination by considering symptoms, exacerbations, lack of response to ICS, inappropriate original indication, and ICS-related adverse events such as pneumonia.

Inhaled Corticosteroid Treatment Regimens and Health Outcomes in a UK COPD Population Study

Background

Inhaled corticosteroids (ICS) are a prevailing treatment option for COPD patients but recent guidelines have relegated their use predominantly to patients with frequent exacerbations. Yet large numbers of patients worldwide are currently treated with ICS-containing regimens. We wished to determine in routine clinical practice how common ICS withdrawal is and the differences in health outcomes between patients managed on ICS-containing and non-ICS containing regimens.

Patients and Methods

COPD patients were identified from the UK primary care electronic healthcare records, between 2014 and 2018. Patients were grouped into three treatment regimens: long-acting beta-agonist (LABA) and inhaled corticosteroids (ICS), LABA and long-acting muscarinic antagonist (LAMA), and triple therapy (LABA, LAMA and ICS). Annual incidence of ICS withdrawal was measured. Multivariable logistic regression was used to identify patient factors associated with withdrawal. Multivariable Poisson regression was used to assess the association of exacerbations and hospitalised pneumonia between the ICS-containing regimens (LABA-ICS and triple therapy) and patients prescribed LABA-LAMA.

Results

Of 117,046 patients, around three-quarters were prescribed ICS-containing inhalers but ICS withdrawal occurred annually in only approximately 2–3% of patients. Exacerbations in the past year, but not a past history of pneumonia, were associated with ICS withdrawal. A total of 31,034 patients using three treatment regimens (LABA-ICS, LABA-LAMA or triple therapy) were assessed for their relative risk of exacerbations and pneumonia; the exacerbation risk was slightly lower in LABA-ICS users but the same in triple therapy users, as compared to LABA-LAMA users (LABA-ICS adjusted IRR=0.82 (95% CI 0.73–0.93), triple adjusted IRR=0.99 (95% CI 0.88–1.11)). There was no difference in the pneumonia risk (LABA-ICS adjusted IRR=0.96 (95% CI 0.71–1.31), triple adjusted IRR=1.16 (95% CI 0.87–1.57)).

Conclusion

Use of ICS-containing inhaled medication is prevalent across the UK while ICS withdrawal from established treatment was relatively uncommon. Exacerbations and pneumonia risk was similar between the ICS-containing and non-ICS containing treatment regimens.