Determinants of initial inhaled corticosteroid use in patients with GOLD A/B COPD: a retrospective study of UK general practice

James D Chalmers,Alicia Gayle,Nick Ramscar,Abigail Tebboth,Andrew Ternouth

doi:10.1038/s41533-017-0040-z

Abstract

Initial use of inhaled corticosteroid therapy is common in patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) A or B chronic obstructive pulmonary disease, contrary to GOLD guidelines. We investigated UK prescribing of inhaled corticosteroid therapy in these patients, to identify predictors of inhaled corticosteroid use in newly diagnosed chronic obstructive pulmonary disease patients. A cohort of newly diagnosed GOLD A/B chronic obstructive pulmonary disease patients was identified from the UK Clinical Practice Research Datalink (June 2005–June 2015). Patients were classified by prescribed treatment, with those receiving inhaled corticosteroid-containing therapy compared with those receiving long-acting bronchodilators without inhaled corticosteroid. In all, 29,815 patients with spirometry-confirmed chronic obstructive pulmonary disease were identified. Of those prescribed maintenance therapy within 3 months of diagnosis, 63% were prescribed inhaled corticosteroid-containing therapy vs. 37% prescribed non-inhaled corticosteroid therapy. FEV1% predicted, concurrent asthma diagnosis, region, and moderate exacerbation were the strongest predictors of inhaled corticosteroid use in the overall cohort. When concurrent asthma patients were excluded, all other co-variates remained significant predictors. Other significant predictors included general practitioner practice, younger age, and co-prescription with short-acting bronchodilators. Trends over time showed that initial inhaled corticosteroid prescriptions reduced throughout the study, but still accounted for 47% of initial prescriptions in 2015. These results suggest that inhaled corticosteroid prescribing in GOLD A/B patients is common, with significant regional variation that is independent of FEV1% predicted.

Highlights

Current international guidelines for chronic obstructive pulmonary disease (COPD) recommend long-acting inhaled bronchodilators, including β2-agonists (LABA) and anti-muscarinic agents (LAMA), as maintenance therapies.[1]
A total of 29,815 patients with spirometry-confirmed COPD of Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage A or B were identified during the study period
This study suggests that a large number of patients with GOLD stage A or B COPD are prescribed inhaled corticosteroids (ICS)-containing therapy within 3 months of diagnosis

Summary

Introduction

Current international guidelines for chronic obstructive pulmonary disease (COPD) recommend long-acting inhaled bronchodilators, including β2-agonists (LABA) and anti-muscarinic agents (LAMA), as maintenance therapies.[1]. Disease (GOLD) 2016 guidelines recommend that ICS therapy is reserved for COPD patients with severe/very severe disease and/or frequent or severe exacerbations.[1] They do not recommend ICS therapy for GOLD stage A or B COPD patients. NICE clinical guidelines for COPD (CG101) recommend ICS in combination with LABA if FEV1 < 50% predicted, and ICS in combination with LAMA + LABA for patients who remain breathless or have exacerbations despite taking LABA + ICS.[2] a significant dissociation has been reported between guideline recommendations and clinical practice,[3, 4] with common use of ICS in patients with GOLD stage A and B COPD.[5] Further research suggests that many patients are prescribed ICS therapy at their initial COPD diagnosis, regardless of disease severity.[6] Recent randomised controlled trials show combined bronchodilator treatment is superior to ICS/LABA in lung function improvement, symptomatic benefit, and reduction in exacerbations, including in patients with

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