Abstract
Inhaled corticosteroids (ICS) are often prescribed for worsening breathlessness, exacerbation frequency or lung function in chronic obstructive pulmonary disease (COPD). In mild-moderate disease and infrequent exacerbations, treatment risks may outweigh benefits and ICS may be withdrawn safely under supervision. A systematic ICS deprescribing programme for patients with mild-moderate COPD was introduced in an east London Clinical Commissioning Group (CCG) in April 2017. Primary care patient record analysis found that prescribing fell from 34.9% (n = 701) in the 18 months pre-intervention to 26.9% (n = 538) by the second year of implementation, decreasing 0.84% per quarter post intervention (p = 0.006, linear regression). The relative decrease was greater than the comparison CCG (23.0% vs. 9.9%). Only South Asian ethnicity was associated with increased cessation (odds ratio 1.48, confidence interval (CI) 1.09–2.01), p = 0.013, logistic regression). Patient outcome data were not collected. A primary care-led programme comprising local education, financial incentivisation and consultant support led to a significant decrease in ICS prescribing.
Highlights
Inhaled corticosteroids (ICS) have been used extensively in the management of chronic obstructive pulmonary disease (COPD) over the past 40 years, derived originally from their use in asthma
Within the mild-moderate COPD intervention cohort, at baseline 87.0% (n = 1748) had a FEV1/forced vital capacity (FVC) ratio < 0.7; 11.9% (n = 240) had a FEV1/FVC ratio ≥ 0.7; 1.0% (n = 21) had no FEV1/FVC recorded in the GP record
By the final quarter of the 2-year post-intervention period, prescribing rates in the mild-moderate COPD group fell to 26.9%
Summary
Inhaled corticosteroids (ICS) have been used extensively in the management of chronic obstructive pulmonary disease (COPD) over the past 40 years, derived originally from their use in asthma. Randomised controlled trials (RCTs) have demonstrated that ICS can reduce the frequency of exacerbation, preserve lung function and slow the decline in quality of life, but are associated with higher prevalence of pneumonia, oral candidiasis and voice hoarseness[1]. Other risks such as reduced bone density, cataract and adrenal suppression have been postulated[2,3]. Others who are likely to benefit include patients with a coexisting diagnosis of asthma (asthma–COPD overlap syndrome), a history of atopy or high blood eosinophils[4] Those patients with mild-to-moderate airflow obstruction on spirometry and infrequent exacerbations may experience greater risks than benefits
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