Factors influencing pharmacological treatment in COPD: a comparison of 2005 and 2014

Abstract

Introduction: The aim was to investigate how the pattern of pharmacological treatment in Swedish patients with chronic obstructive pulmonary disease (COPD) has changed over a decade, and to identify factors associated with treatment. Methods: Data on patient characteristics and pharmacological treatment were collected using questionnaires from two separate cohorts of randomly selected primary and secondary care patients with a doctor’s diagnosis of COPD in central Sweden, in 2005 (n = 1111) and 2014 (n = 1329). Cross-tabulations and chi-square tests were used to compare maintenance treatment in 2005 and 2014, and to investigate the distribution of treatment by the 2017 Global Initiative for Obstructive Lung Disease (GOLD) ABCD groups. Multinomial logistic regression was used to analyze associations with the major types of recommended treatments: bronchodilator therapy, combined long-acting beta-2-antagonists (LABA) + inhaled corticosteroids (ICS), and triple inhaled therapy. Results: The proportion of patients with no maintenance treatment, with only LABA + ICS, and with sole ICS statistically significantly decreased (36 vs. 31%, 16 vs. 12% and 5 vs. 2%, respectively), and the proportion with triple inhaled therapy statistically significantly increased (29 vs. 40%). In 2014, triple inhaled therapy was the most common treatment in all GOLD groups except group A. In 2014, previous frequent exacerbations [OR (95% CI) 2.34 (1.62 to 3.36)], worse COPD Assessment Test score [1.07 (1.05 to 1.09)], female sex [2.13 (1.56 to 2.91)], and access to a specific responsible doctor [1.95 (1.41 to 2.69)] were associated with triple inhaled therapy. Current smoking [0.40 (0.28 to 0.57)] and overweight [0.62 (0.41 to 0.93)] were inversely associated with triple inhaled therapy. Conclusions: Over the last decade, triple inhaled therapy has increased, and no maintenance treatment, ICS, or LABA + ICS has decreased. Triple inhaled therapy is the most common treatment and is associated with previous exacerbations, higher symptom level, female sex, and having a specific responsible doctor.

<p>Geographical and sociodemographic differences in discontinuation of medication for Chronic Obstructive Pulmonary Disease – A Cross-Classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)</p>

“…The prevalence of discontinuation in our study was similar to that observed in previous publications, 40 – 42 in spite of different definitions of medication adherence/discontinuation being used. Haupt et al 41 saw that among patients who had received any inhaled medication, 24% received it only once during a 5-year period.…”

“…However, short-acting pharmacological agents that may be prescribed for non-chronic conditions were included in that study. In another study, Sundh et al 40 found that 22% of COPD patients treated at hospitals lacked prescribed maintenance medication. Those results concerning discontinuation, low-dosage coverage or no maintenance treatment on discharge from hospital are in line with our findings.…”

“…As indicated in Figure 3 , and while not statistically significant in all age categories, we found men to have a higher absolute risk of therapy discontinuation than women, which is in line with previous research. 40 , 45 Possible explanations include findings that the lung function of female smokers deteriorates more rapidly than among male smokers, causing more severe COPD 46 , 47 and, thereby, increased adherence with maintenance therapy. However, we need more research on gender disparities in COPD maintenance treatment.…”

Are there specific clinical characteristics associated with physician’s treatment choices in COPD?

“…The importance of exacerbations as triggers of ICS prescription has been suggested in several other studies [14, 15, 30]. Many of these also identified associations between symptoms burden and treatment intensity [14, 23, 31]. In UK general practices, ICS use in GOLD A/B patients (in whom there is theoretically no indication of ICS according to most guidelines) appears associated with the level of airflow obstruction, concurrent asthma diagnosis and exacerbation rates as well as the region of the practice [30], suggesting that although markers of disease severity play a role, less objective or “scientific” factors are also involved.…”

Double or Triple Therapy in Chronic Obstructive Pulmonary Disease

“…However, there is also real-world evidence that patients with COPD are more likely to initiate open-triple therapy following initiation with LAMA monotherapy, compared with LABA/ICS therapy 9 . It has been speculated that, at least in Sweden, the widespread use of triple therapy is due to the chronic characteristics of the disease, with a documented high proportion of persistent breathlessness in spite of maximum optimised treatment 10 . Other potential explanations may be increased availability of inhaled therapy in different devices and combinations, overtreatment due to heavy marketing from pharmaceutical companies, and increased awareness and implementation of GOLD ABCD recommendations.…”