Overtreatment of COPD with Inhaled Corticosteroids - Implications for Safety and Costs: Cross-Sectional Observational Study

Abstract

IntroductionCombined inhaled long-acting beta-agonists and corticosteroids (LABA+ICS) are costly. They are recommended in severe or very severe chronic obstructive pulmonary disease (COPD). They should not be prescribed in mild or moderate disease. In COPD ICS are associated with side-effects including risk of pneumonia. We quantified appropriateness of prescribing and examined the risks and costs associated with overuse. MethodsData were extracted from the electronic and paper records of 41 London general practices (population 310,775) including spirometry, medications and exacerbations. We classified severity, assessed appropriateness of prescribing using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for 2009, and performed a sensitivity analysis using the broader recommendations of the 2011 revision.Results3537 patients had a diagnosis of COPD. Spirometry was recorded for 2458(69%). 709(29%) did not meet GOLD criteria. 1749(49%) with confirmed COPD were analysed: 8.6% under-treated, 38% over-treated. Over-prescription of ICS in GOLD stage I or II (n=403, 38%) and in GOLD III or IV without exacerbations (n=231, 33.6%) was common. An estimated 12 cases (95%CI 7-19) annually of serious pneumonia were likely among 897 inappropriately treated. 535 cases of overtreatment involved LABA+ICS with a mean per patient cost of £553.56/year (€650.03). Using the broader indications for ICS in the 2011 revised GOLD guideline 25% were still classified as over-treated. The estimated risk of 15 cases of pneumonia (95%CI 8-22) in 1074 patients currently receiving ICS would rise by 20% to 18 (95%CI 9.8-26.7) in 1305 patients prescribed ICS if all with GOLD grade 3 and 4 received LABA+ICS. ConclusionOver-prescription of ICS in confirmed COPD was widespread with considerable potential for harm. In COPD where treatment is often escalated in the hope of easing the burden of disease clinicians should consider both the risks and benefits of treatment and the costs where the benefits are unproven.

Inhaled corticosteroids and the increased risk of pneumonia: what’s new? A 2015 updated review

“…In a study that analyzed data extracted from records of London general practices, the investigators reported a 25% incidence of overtreatment with ICS when compared with the 2011 revised GOLD guidelines' recommendations [White et al 2013]. According to another observational study from Italy, ICS were over-prescribed in up to 62% of the subjects [Corrado and Rossi, 2012].…”

Overdiagnosis of COPD: precise definitions and proposals for improvement

“…Overprescription of inhaled steroids was associated with adverse events such as pneumonia, and higher costs. 6 In COPD, where treatment is often escalated in the hope of easing the burden of disease, clinicians should confirm the diagnosis before treatment, and then consider both the risks and benefits of treatment, and the costs where the benefits are unproven. Recently, Carter et al 7 proposed a theoretical, generic terminology to clearly differentiate within clinical situations regarding inadequate diagnosis.…”

Low Use and Adherence to Maintenance Medication in Chronic Obstructive Pulmonary Disease in the General Population

“…This observation seems to support a recent study indicating a tendency toward overtreatment with inhaled corticosteroids in mild COPD. 32 Lastly, as a minor limitation, the GOLD A-D grading was not officially implemented in clinical practice until 2011. 10 Nevertheless, our analyses clearly show that the GOLD A-D grading was already an important driver of treatment in COPD in the general population even before the official implementation.…”