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

Abstract

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.

Characterisation of patients with chronic obstructive pulmonary disease initiating single-device inhaled corticosteroids/long-acting β2-agonist dual therapy in a primary care setting in England

“…Conversely, the treatment patterns observed may be consistent with NICE guidelines, which recommend initiatingtreatment with ICS/LABA dual therapy in patients withasthmatic features 5. This is in line with several studies that have shown disparities between international treatment recommendations and national prescribing practices in the UK and in other countries 20–24…”

“…5 This is in line with several studies that have shown disparities between international treatment recommendations and national prescribing practices in the UK and in other countries. [20][21][22][23][24] Disparities between a particular set of recommendations and prescribing practices in primary care may be related to variation in familiarity and implementation across different international, national and local guidelines. 23 25 In support of this, we observed geographical variation in prescribing patterns, with most prevalent and incident users located in western regions, likely due to differing practices across local clinical commissioning groups and the greater representation of patients in these regions in the CPRD-Aurum database.…”

Inhaled Corticosteroid Use Among COPD Patients in Primary Care in Spain

“…Our results concur with other recent studies that confirmed the association between symptoms and ICS prescription. 29 , 30 …”

“…Our results concur with other recent studies that confirmed the association between symptoms and ICS prescription. 29,30 Understanding the role of eosinophils in COPD has increased over the last years. 31 Within our sample, blood eosinophils were not associated with ICS use, which in addition to the significant proportion of patient with missing eosinophil counts, could be suggesting a lack of awareness of the usefulness of eosinophil counts for the management of COPD within primary care.…”

Prescribing Patterns for Long-Acting Inhaled Bronchodilators Among Rural Adults With Chronic Obstructive Pulmonary Disease

“…Among patients with advanced COPD, those figures dropped to 59% and 69%, respectively [ 9 ]. A recent Canadian study of prescription patterns for COPD found overprescribing of inhaled corticosteroids and underprescribing of LABD [ 14 ]. In contrast, our analyses showed a very high proportion of COPD patients having ever received a prescription for LABD during the study period for both spirometry-based and hospitalization-based definitions of COPD.…”