COPD treatment pathways in France: a retrospective analysis of electronic medical record data from general practitioners

Abstract

BackgroundIncreasing availability of therapeutic options for COPD may drive new treatment pathways. This study describes COPD treatment in France, focusing on identifying initial treatment modifications in patients with COPD who either initiated long-acting bronchodilator (LABD)-based therapy or escalated to triple therapy (long-acting muscarinic antagonist [LAMA] + long-acting β2-agonist [LABA] + inhaled corticosteroid [ICS]).MethodsThis retrospective analysis of patients with COPD in a large general practitioner database (IQVIA Longitudinal Patient Database) in France included two cohorts: Cohort 1 – new initiators of LABD-based therapy (LAMA, LABA, LAMA + LABA, LAMA + ICS, LABA + ICS or LAMA + LABA + ICS); Cohort 2 – patients escalating to triple therapy from mono- or dual-bronchodilator-based maintenance treatment. Both cohorts were indexed on the date of initiation/escalation (January 2008–December 2013), and the first treatment modification (at class level) within the 18-month post-index observational period was described. Five mutually exclusive outcomes were defined: continuous use (no modification), discontinuation (permanent [≥91 days with no restart] or temporary [≥91 days with subsequent restart]), switch, and augmentation (Cohort 1 only). Exploratory analysis of Cohort 1 explored potential drivers of treatment initiation.ResultsOverall, 5,065 patients initiated LABD-based therapy (Cohort 1), and 501 escalated to triple therapy (Cohort 2). In Cohort 1, 7.0% of patients were continuous users, 46.5% discontinued permanently, 28.5% discontinued temporarily, 2.8% augmented (added LAMA and/or LABA and/or ICS), and 15.2% switched therapy. In Cohort 2, 18.2% of patients were continuous users, 7.2% discontinued permanently, 27.9% discontinued temporarily, and 46.7% switched therapy. Exploratory analyses showed that time since COPD diagnosis was first recorded, pre-index exacerbation events, and concomitant medical conditions were potential drivers of initial maintenance treatment choices.ConclusionDiscontinuation among new initiators of LABD-based therapy was high in France, whereas few switched or augmented treatment. In comparison, permanent discontinuation within 18 months was low in patients escalating to triple therapy.

Prescribing Pathways to Triple Therapy: A Multi-Country, Retrospective Observational Study of Adult Patients with Chronic Obstructive Pulmonary Disease

“…After stepping down or discontinuing from triple therapy, most patients recorded ICS ? LABA or LAMA only, which corresponds with the findings by Meeraus et al in France [21]. The availability and actual use of LAMA/LABA FDCs was very low during the study period, which may impact prescription choices and the decision to recommend that a patient steps down in their medication regimen.…”

“…Specific pathways to triple therapy are likely to differ across countries due to differences in prescribing practices [38]. Similar to previous studies by Brusselle et al in the UK [18] and Meeraus et al in France [21], in our study, ICS ? LABA was the most common treatment pathway prior to triple therapy in the UK, Germany and Italy, and the second most common pathway in France and Australia.…”

“…The higher prevalence of asthma in several countries (Germany, France, and Australia) may have resulted from previously misdiagnosing COPD as asthma [23]. It should be noted that the previous studies that evaluated pathways to triple therapy, by Brusselle et al and Wurst et al in the UK and Meeraus et al in France, excluded patients with a diagnosis of asthma [18,20,21].…”

“…The availability and actual use of LAMA/LABA FDCs was very low during the study period, which may impact prescription choices and the decision to recommend that a patient steps down in their medication regimen. A previous study of two cohorts of French patients showed lower rates of discontinuation in patients who received triple therapy versus those who received long-acting bronchodilators only, and that guidelines were not always followed [21]. Withdrawal of the ICS component can be considered in the case of adverse effects (such as pneumonia), a reported lack of efficacy [4], or in patients without an established frequent exacerbation history [43].…”

“…However, little is known about how treatment patterns align with treatment guidelines across countries, with some evidence suggesting poor concordance between real-world prescribing and GOLD recommendations in singlecountry studies [18][19][20][21]. Indeed, some patients may be treated with triple therapy prior to a full formal diagnosis of COPD, or may initially be treated with triple therapy post-diagnosis [18,19], which may still follow recommendations if patients were classified as severe (GOLD group D) at the time of diagnosis [14].…”