A new study published in the International Journal of COPD highlights a problem with over-prescription of inhaled corticosteroids for low-risk patients with chronic obstructive pulmonary disease (COPD). The study is based on 11,858 patients in UK primary care and was carried out by an international team of researchers together with Research in Real Life Ltd. The study identifies substantial discrepancies between prescribing practices and international guideline recommendations. A high proportion of patients with COPD are prescribed inhaled corticosteroids upon initial diagnosis resulting in an inevitable drift to so-called triple therapy, which according to guidelines should be reserved only for patients with severe and high-risk COPD.
While there is no cure for COPD, pharmacological treatment can relieve the impact of symptoms, including chronic cough, sputum production and breathing difficulties. Current guidelines recommend initial therapy with a long-acting muscarinic antagonist and/or a long-acting beta-agonist. The further addition of inhaled corticosteroids is referred to as triple therapy. Inhaled corticosteroids do not have superior efficacy, and long-term use may be associated with issues of diabetes, osteoporosis and pneumonia, which are common additional complications of COPD. Triple therapy is therefore only recommended for patients with severe COPD and frequent exacerbations (especially for exacerbations of COPD requiring treatment with oral corticosteroids).
Professor Guy Brusselle at Ghent University Hospital and lead author of the article stated:
"Despite the availability of excellent guidelines, this study shows that 28% of patients with lower-risk COPD were prescribed triple therapy at their initial COPD consultation. Furthermore, of the patients who were eventually prescribed triple therapy, over 60% received inhaled corticosteroids (ICS) in their first prescription, implying that the initial ICS prescription often leads into triple therapy even in cases where ICS is not appropriate. Primary-care physicians do not always manage COPD according to the recommendations and guidelines. Inappropriate and long-term overuse of inhaled corticosteroids (ICS) and triple therapy is potentially harmful for COPD patients (especially for those who do not experience exacerbations) and is likely to increase the strain on healthcare resources. There is, therefore, an urgent need to address the issues of awareness and adherence to clinical practice guidelines among physicians, and to review the dissemination and implementation of guidelines in the future"
This study describes important prescription pathways that lead to triple therapy and highlights the common practice of ICS and triple therapy overuse.
The authors propose that "This reflects the persistent uncertainties of physicians in prescribing the most appropriate therapy to patients with COPD". The implications of this make a case for action, which could have a substantial positive impact on the treatment outcomes of COPD patients.