<p>The Long-Term Burden of COPD Exacerbations During Maintenance Therapy and Lung Function Decline</p>

Abstract

Introduction Early identification of preventable risk factors of COPD progression is important. Whether exacerbations have a negative impact on disease progression is largely unknown. We investigated whether the long-term occurrence of exacerbations is associated with lung function decline at early stages of COPD. Methods Patients diagnosed with mild/moderate COPD (obstruction and FEV 1 % predicted 50–90%), aged ≥35 years, and a smoking history, who had ≥6 years of UK electronic medical records after initiation of maintenance therapy were studied. Multilevel mixed-effect linear regression was performed to determine the association between the count of any year in which the patient had ≥1 exacerbation over a 6-year period and FEV 1 decline, adjusted for sex, age, anthropometrics and smoking habits. Exacerbations were defined as any prescription for an acute oral corticosteroid course and/or lower respiratory-related antibiotics and/or any COPD-related emergency or inpatient hospitalization. Results Of 11,337 patients included (mean age 65 years; 49% female) 31.6%, 23.3%, 16.6%, 11.6%, 8.1%, 5.3% and 3.4% had 0, 1, 2, 3, 4, 5 and 6 years with ≥1 exacerbation. The mean annual FEV 1 decline accelerated by 1.50 mL/year (95% Confidence Interval 1.02; 1.98) with every additional year with ≥1 exacerbation from 31.0 mL/year in subjects without any exacerbation to 40.0 mL/year in patients experiencing ≥1 exacerbation every year. Patients with more years with ≥1 exacerbation had a lower mean FEV 1 at first diagnosis: 14.7 mL (11.7; 17.8) lower with every additional year with exacerbations. When counting years with ≥2 exacerbations, greater effects were observed (2.19 [1.50; 2.88] mL/year excess decline per year with ≥2 exacerbations; 16.5 mL [12.1; 20.8] lower FEV 1 at diagnosis). Conclusion Patients who experienced a greater exacerbation burden after initiation of maintenance therapy had worse lung function at diagnosis and a more rapid lung function decline thereafter, which emphasizes the need for better treatment strategies.

CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care

“…51 The NICE guidelines also recommend short-term OCS use (typically 5 days) in all people admitted to hospital with an exacerbation of COPD (if no contraindications) and to consider their use in community settings when an exacerbation is associated with "a significant increase in breathlessness that interferes with daily activities". 13 OCS can be associated with significant side effects in both the short and long term. 93 Quality Standard 4: Appropriate Follow-Up…”

“… 12 Furthermore, patients who experience a greater exacerbation burden after initiation of maintenance therapy have worse lung function at diagnosis and a more rapid lung function decline thereafter, emphasizing the need for better treatment strategies. 13 These findings highlight the importance of earlier intervention among patients with COPD, to more proactively diagnose and manage optimally. Current gaps in COPD management and the need for improved quality of care have been recognized both in the UK and the USA.…”

Overcoming Therapeutic Inertia to Reduce the Risk of COPD Exacerbations: Four Action Points for Healthcare Professionals

“…[29][30][31][32] For instance, many people diagnosed with COPD are not prescribed maintenance inhaled therapy, despite evidence that this reduces the exacerbation risk in some patients. 12,41 Of those receiving treatment, up to three-quarters of people that experience two or more exacerbations continue to be undertreated according to GOLD recommendations. 42 Halpin et al reported that only between 33% and 60% of patients are treated appropriately according to GOLD recommendations.…”

“…1,3 Patients who experience more exacerbations after starting maintenance inhaled therapy show a particularly rapid decline in lung function. 12 The time between exacerbations shortens with more frequent exacerbations. 1 Exacerbations seem to cluster, which partly accounts for the high hospital readmission rates.…”

Comprehensive care programmes in chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials and real-world studies

“…It is a significant public health problem worldwide with an estimated prevalence between 11 and 26% in the BOLD Study Document "International variation in the prevalence of COPD". It is also a significant cause of hospitalizations and mortality, placing a high burden on healthcare systems [2][3][4][5][6] . These hospitalizations represent the single largest source of expenditure on patients with COPD 7 .…”