<p>Inhaled Corticosteroid Treatment Regimens and Health Outcomes in a UK COPD Population Study</p>

Abstract

Background: Inhaled corticosteroids (ICS) are a prevailing treatment option for COPD patients but recent guidelines have relegated their use predominantly to patients with frequent exacerbations. Yet large numbers of patients worldwide are currently treated with ICS-containing regimens. We wished to determine in routine clinical practice how common ICS withdrawal is and the differences in health outcomes between patients managed on ICScontaining and non-ICS containing regimens. Patients and Methods: COPD patients were identified from the UK primary care electronic healthcare records, between 2014 and 2018. Patients were grouped into three treatment regimens: long-acting beta-agonist (LABA) and inhaled corticosteroids (ICS), LABA and long-acting muscarinic antagonist (LAMA), and triple therapy (LABA, LAMA and ICS). Annual incidence of ICS withdrawal was measured. Multivariable logistic regression was used to identify patient factors associated with withdrawal. Multivariable Poisson regression was used to assess the association of exacerbations and hospitalised pneumonia between the ICS-containing regimens (LABA-ICS and triple therapy) and patients prescribed LABA-LAMA. Results: Of 117,046 patients, around three-quarters were prescribed ICS-containing inhalers but ICS withdrawal occurred annually in only approximately 2-3% of patients. Exacerbations in the past year, but not a past history of pneumonia, were associated with ICS withdrawal. A total of 31,034 patients using three treatment regimens (LABA-ICS, LABA-LAMA or triple therapy) were assessed for their relative risk of exacerbations and pneumonia; the exacerbation risk was slightly lower in LABA-ICS users but the same in triple therapy users, as compared to LABA-LAMA users (LABA-ICS adjusted IRR=0.82 (95% CI 0.73-0.93), triple adjusted IRR=0.99 (95% CI 0.88-1.11)). There was no difference in the pneumonia risk (LABA-ICS adjusted IRR=0.96 (95% CI 0.71-1.31), triple adjusted IRR=1.16 (95% CI 0.87-1.57)). Conclusion: Use of ICS-containing inhaled medication is prevalent across the UK while ICS withdrawal from established treatment was relatively uncommon. Exacerbations and pneumonia risk was similar between the ICS-containing and non-ICS containing treatment regimens.

Treatment Transitions in Chronic Obstructive Pulmonary Disease: Retrospective Analyses of US and UK Healthcare Databases

“…Regarding de-escalation from triple therapy, we found a very small percentage (0.5%) of patients in the UK switching from triple therapy to LAMA/LABA at 2MT (as discussed earlier in this section, the larger proportion of patients appearing to de-escalate to LAMA or LABA/ICS likely reflects patients receiving a new prescription for one component of an open triple combination). This is consistent with a previous large-scale analysis of UK primary care health records between 2014 and 2018, in which the annual incidence of ICS withdrawal was also found to be very low (2-3%) [14].…”

“…Despite clear guidance that ICS should be reserved for patients with asthma, a history of exacerbations or high levels of blood eosinophils, evidence from real-world studies suggests that ICS are often inappropriately prescribed [11][12][13][14], which can expose patients to the unnecessary risk of side effects such as pneumonia, osteoporosis and diabetes [15][16][17][18]. In the accompanying paper in this issue, we report that more patients in both the US and UK received ICS-containing therapies at initiation of first maintenance therapy (1MT) than would be expected based on their exacerbation history, suggesting overprescribing.…”

Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study

“…Despite the published studies and recommendations, ICS withdrawal is very infrequent in real life in primary care [ 31 , 32 ]. In our study, only 2% of patients on TT discontinued ICS during 1 year, which is similar to the 2% to 3.5% rates of discontinuation of ICS observed between 2014 and 2018 in another large primary care study in the UK [ 33 ]. However, other studies have observed higher rates, such as the 15% observed in a population-based study on + 34,000 patients on TT in primary care in Spain [ 34 ] or the 16% in Korea [ 35 ].…”

Real-World Treatment Patterns of Multiple-Inhaler Triple Therapy Among Patients with Chronic Obstructive Pulmonary Disease in UK General Practice

“… 32 In a UK primary care database study of 31,034 COPD patients, exacerbation risk was lower in LABA/ICS users, but the same in triple therapy and LAMA/LABA users. 33 A matched cohort study using a US Medicare claims database observed fewer severe COPD exacerbations for LAMA/LABA users compared with triple therapy (9.0% vs 16.1%), and the LAMA/LABA users had a longer time to these events. 34 A claims data study in France observed a similar number of COPD exacerbations for triple- and dual-therapy users in a 12-month period (2.4 vs 2.3, respectively; p=0.45), but the patients receiving triple therapy were more likely to receive oral corticosteroids (49.1% vs 40.4%, p=0.003) or be hospitalized for COPD (35.3% vs 25.1%, p=0.002).…”