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Factors influencing treatment escalation from long-acting muscarinic antagonist monotherapy to triple therapy in patients with COPD: a retrospective THIN-database study

John R Hurst, Maria Dilleen, Kevin Morris, Sian Hills, Birol Emir and Rupert Jones
Int J Chron Obstruct Pulmon Dis 2018;13:781–92.
doi: 10.2147/COPD.S153655

Inappropriate use of inhaled corticosteroids (ICSs) in patients with chronic obstructive pulmonary disease (COPD) can have serious clinical implications, and contributes to the economic burden of COPD. In this retrospective non-interventional database study, John Hurst from University College London and colleagues examined the records of 14,866 COPD patients who received long-acting muscarinic antagonist (LAMA) monotherapy as their initial treatment, and recorded the time until treatment was escalated to ‘triple therapy’, a combination of LAMA plus ICS and a long-acting beta2-agonist (LABA).

In total, 6,482 patients (43.6%) received treatment escalation. Of these patients, 85% of escalations occurred within two years of starting LAMA monotherapy, with a median time to escalation of 155 days. In multivariate analysis, an acute COPD exacerbation was the variable most strongly associated with treatment escalation (hazard ratio: 2.11). Other variables positively associated with escalation were a diagnosis of asthma, greater breathlessness according to the MRC Dyspnoea scale, contact with healthcare services and number of short-acting bronchodilator prescriptions.

Results were analysed according to patients’ Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade, based on the 2011/2013 guidelines (which stratified patients based on forced expiratory volume in 1 second (FEV1) and Medical Research Sandra (MRC) score) and 2017 guidelines (derived from MRC score and number of exacerbations). Fewer treatment-escalated patients were classified as groups C or D under the 2017 strategy, compared with the 2011/2013 edition. This suggests that many patients were being overtreated according to the GOLD 2017 strategy; reviewing patients’ treatment in the light of the most recent GOLD strategy could reduce inappropriate prescription of these powerful drugs.

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