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Neches García V, Vallejo-Aparicio LA, Ismaila AS, Sicras-Mainar A, Sicras-Navarro A, González C, Cuervo R, Shukla S, García-Peñuela M. Clinical and Economic Impact of Long-Term Inhaled Corticosteroid Withdrawal in Patients with Chronic Obstructive Pulmonary Disease Treated with Triple Therapy in Spain. Int J Chron Obstruct Pulmon Dis 2022; 17:2161-2174. [PMID: 36101793 PMCID: PMC9464437 DOI: 10.2147/copd.s367708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the clinical and economic impact of inhaled corticosteroid (ICS) withdrawal in Spanish patients with COPD receiving triple therapy (TT) with ICS, long-acting β2-agonist (LABA), and long-acting muscarinic antagonist (LAMA). Patients and Methods This was an observational, retrospective study of BIG-PAC database medical records. Patients aged ≥40 years receiving TT from 2016 to 2018 were followed for 1 year. Two cohorts were identified: patients continuing TT (ICS+LABA+LAMA), and patients receiving TT with ICS withdrawn (LABA+LAMA). Variables included medication, exacerbations (moderate and severe), pneumonia, mortality, health resource use (HRU), and cost per patient/year. Cohorts were compared using propensity score matching (PSM). Multivariate statistical analysis using analysis of covariance and Cox proportional risks was conducted. Results Of 6541 patients included, 5740 (87.8%) continued TT and 801 (12.2%) had ICS withdrawn. Patients with ICS withdrawal were younger, had lower disease burden, higher ICS doses, and more exacerbations compared with those continuing ICS. PSM matched 795 patients in each cohort. Mean age was 68.5 years (SD: 11.2), 69.9% were male, and mean Charlson index was 2.0. Patients with ICS withdrawal had more total exacerbations in the 12 months following withdrawal compared with patients continuing TT (36.6% vs 31.4%; p=0.030). No significant differences were found for pneumonia (3.3% vs 3.6%; p=0.583) and mortality (9.9% vs 7.5%; p=0.092). Median time to first exacerbation was shorter in patients with ICS withdrawal compared with those continuing ICS (HR: 0.69, 95% CI: 0.57–0.83; p<0.001). Mean health cost per patient/year among patients with ICS withdrawal was higher than those continuing TT (€2993 vs €2130; p<0.001). Conclusion ICS withdrawal in patients with COPD receiving TT was associated with increased exacerbations, HRU, and costs compared with continuing TT, with health and economic impacts on patients and the Spanish National Healthcare System, respectively. Pneumonia and mortality rates were similar between groups.
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Affiliation(s)
| | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Cruz González
- Pneumology Unit, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Soham Shukla
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA
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Magnussen H, Lucas S, Lapperre T, Quint JK, Dandurand RJ, Roche N, Papi A, Price D, Miravitlles M. Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study. Respir Res 2021; 22:25. [PMID: 33478491 PMCID: PMC7818945 DOI: 10.1186/s12931-021-01615-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are indicated for prevention of exacerbations in patients with COPD, but they are frequently overprescribed. ICS withdrawal has been recommended by international guidelines in order to prevent side effects in patients in whom ICS are not indicated. METHOD Observational comparative effectiveness study aimed to evaluate the effect of ICS withdrawal versus continuation of triple therapy (TT) in COPD patients in primary care. Data were obtained from the Optimum Patient Care Research Database (OPCRD) in the UK. RESULTS A total of 1046 patients who withdrew ICS were matched 1:4 by time on TT to 4184 patients who continued with TT. Up to 76.1% of the total population had 0 or 1 exacerbation the previous year. After controlling for confounders, patients who discontinued ICS did not have an increased risk of moderate or severe exacerbations (adjusted HR: 1.04, 95% confidence interval (CI) 0.94-1.15; p = 0.441). However, rates of exacerbations managed in primary care (incidence rate ratio (IRR) 1.33, 95% CI 1.10-1.60; p = 0.003) or in hospital (IRR 1.72, 95% CI 1.03-2.86; p = 0.036) were higher in the cessation group. Unsuccessful ICS withdrawal was significantly and independently associated with more frequent courses of oral corticosteroids the previous year and with a blood eosinophil count ≥ 300 cells/μL. CONCLUSIONS In this primary care population of patients with COPD, composed mostly of infrequent exacerbators, discontinuation of ICS from TT was not associated with an increased risk of exacerbation; however, the subgroup of patients with more frequent courses of oral corticosteroids and high blood eosinophil counts should not be withdrawn from ICS. Trial registration European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS30851).
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Affiliation(s)
- Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, Member of the German Center of Lung Research, Grosshansdorf, Germany
| | | | - Therese Lapperre
- Department of Respiratory Medicine, Antwerp University Hospital, Edegem, Denmark
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, UK
| | - Jennifer K Quint
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Wilrijk, UK
| | - Ronald J Dandurand
- CIUSSS de L'Ouest-de-L'Île-de-Montréal, Montreal Chest Institute, Meakins-Christie Laboratories, Oscillometry Unit and Centre for Innovative Medicine, McGill University Health Centre and Research Institute, Montreal, QC, Canada
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University of Paris, UMR1016, Cochin Institute, Paris, France
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall D'Hebron, Vall D'Hebron Institut de Recerca (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
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Chalmers JD, Laska IF, Franssen FME, Janssens W, Pavord I, Rigau D, McDonnell MJ, Roche N, Sin DD, Stolz D, Suissa S, Wedzicha J, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline. Eur Respir J 2020; 55:13993003.00351-2020. [PMID: 32366483 DOI: 10.1183/13993003.00351-2020] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL-1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.
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Affiliation(s)
- James D Chalmers
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
| | - Irena F Laska
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,These three authors contributed equally to the development of this guideline
| | - Frits M E Franssen
- Dept of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Dept of Research and Education, CIRO, Horn, The Netherlands
| | - Wim Janssens
- Clinical Dept of Respiratory Diseases, UZ Leuven and Breathe, Dept CHROMETA, KU Leuven, Leuven, Belgium
| | - Ian Pavord
- Oxford NIHR Respiratory BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | | | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, AP-HP Centre University of Paris, Cochin Institute (UMR1016), Paris, France
| | - Don D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital and Respiratory Division, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital and Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Jadwiga Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
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