Primary care cohort study in the sequence of diagnosing chronic respiratory diseases and prescribing inhaled corticosteroids

Exploring the impact of comorbid dementia on exacerbation occurrence in general practice patients with chronic obstructive pulmonary disease

OBJECTIVE

Previous studies have shown an increased risk of dementia in patient with COPD, but whether comorbid dementia modifies the risk of exacerbations in patients with COPD is unknown. We explored exacerbation occurrence in patients with COPD with comorbid dementia and compared this to patients with COPD without comorbid dementia.

METHODS

We performed a retrospective cohort study based on medical record data from 88 Dutch general practices. Patients diagnosed with COPD and comorbid dementia (n = 244, index group) were matched 1:1 to patients with COPD without comorbid dementia (n = 244, controls). Exacerbations were assessed 1 year before and 1 year after the dementia diagnosis (or corresponding date in controls) and compared between index and control groups by calculating Rate Ratios (RRs).

RESULTS

Average number of COPD exacerbations after dementia diagnosis increased from 5 to 14 per 100 patient years in the index group (RR = 2.70, 95%CI 1.42-5.09; p = 0.02) and from 17 to 30 per 100 patient years in the control group (RR = 1.74, 1.19-2.54; p = 0.04). These RRs did not significantly differ between the index and control groups (RR ratio = 1.55, 0.74-3.25; p = 0.25).

DISCUSSION

We conclude that although the risk of exacerbation increased after patients with COPD were diagnosed with dementia, their change in exacerbation risk did not seem to differ from the change observed in patients with COPD without comorbid dementia. However, as our study was hypothesis-generating in nature, further investigations on the subject matter are needed.

Defined daily dose definition in medication adherence assessment in asthma

Adherence to inhaled corticosteroids (ICS) has been described as poor. In adherence studies, if the actual prescribed dosing is not available, generic defined daily doses (DDD) are applied instead when assessing adherence. We evaluated asthma patients' adherence in a large prospective follow-up survey. We also analysed whether World Health Organization (WHO) and Global Initiative for Asthma (GINA) reference doses give different results. The current study was cross-sectional and included respondents attending to HeSSup follow-up questionnaire in 2012. Altogether 1,141 of 12,854 adult participants answered positively to the question about having asthma. According to the Finnish Social Insurance Institutions' medication register, 686 of them had purchased ICS medication during 2011. DDDs for ICS by WHO as well as medium doses from GINA report were used as reference doses to evaluate adherence. To estimate adherence to ICS, the proportion of days covered (PDC) over one year was calculated for every patient. If the lower limit of GINA medium ICS dose was used as a reference, 65% of the patients were adherent (PDC ≥ 80%). Use of WHO's DDD as reference halved the proportion of adherent patients. Adherence was higher among those using a combination inhaler of corticosteroid and long-acting β₂-agonist compared to those using steroid only inhalers. Use of WHO's daily defined doses as reference values may lead to underestimation of adherence to inhaled corticosteroids. Thus, attention should be paid when choosing the reference doses for the evaluation of adherence to inhaled corticosteroids in asthma.

Treatment of COPD Groups GOLD A and B with Inhaled Corticosteroids in the COSYCONET Cohort - Determinants and Consequences

Background

In COPD patients of GOLD groups A and B, a high degree of treatment with inhaled corticosteroids (ICS) has been reported, which is regarded as overtreatment according to GOLD recommendations. We investigated which factors predict ICS use and which relationship it has to clinical and functional outcomes, or healthcare costs.

Methods

We used pooled data from visits 1 and 3 of the COSYCONET cohort (n=2741, n=2053, interval 1.5 years) including patients categorized as GOLD grades 1-4 and GOLD group A or B at both visits (n=1080). Comparisons were performed using ANOVA, and regression analyses using propensity matching and inverse probability weighting to adjust for differences between ICS groups. These were defined as having ICS at both visits (always) vs no ICS at both visits (never). Measures were divided into predictors of ICS treatment and outcomes.

Results

Among 1080 patients, 608 patients were eligible for ICS groups (n=297 never, n=311 always). Prior to matching, patients with ICS showed significantly (p<0.05 each) impaired lung function, symptoms and exacerbation history. After matching, the outcomes generic quality of life and CO diffusing capacity were increased in ICS patients (p<0.05 each). Moreover, costs for respiratory medication, but not total health care costs, were significantly elevated in the ICS group by 780€ per year.

Conclusion

ICS therapy in COPD GOLD A/B patients can have small positive and negative effects on clinical outcomes and health care costs, indicating that the clinical evaluation of ICS over-therapy in COPD requires a multi-dimensional approach.

Pragmatic trial on inhaled corticosteroid withdrawal in patients with COPD in general practice

The therapeutic value of inhaled corticosteroids (ICSs) for COPD is limited. In published RCTs, ICS could be withdrawn in COPD patients without increasing exacerbation risk when bronchodilator treatment is optimized. Here we report on the feasibility and risks of ICS withdrawal in Dutch general practice for COPD patients without an indication for ICSs. In our pragmatic trial, general practitioners decided autonomously which of their COPD patients on ICS treatment could stop this, how this was done, and whether additional bronchodilator therapy was needed. We recruited 62 COPD patients (58 analysed) who were eligible for ICS withdrawal in 79 practices. In 32 patients (55.2%, 95% CI: 42.5–67.3%) ICS was withdrawn successfully, 19 (32.8%, 95% CI: 22.1–45.6%) restarted ICS treatment within six months, 12 patients (20.7%, 95% CI: 12.3–32.8%) had a moderate exacerbation, and one patient had a severe exacerbation. ICS withdrawal was successful in just over half of the patients with COPD without an indication for ICS.

Prevalence of Asthma Characteristics in COPD Patients in a Dutch Well-Established Asthma/COPD Service for Primary Care

Purpose

Primary care COPD guidelines indicate that COPD patients with asthma characteristics should be treated as having asthma. This study aims to describe the prevalence of asthma characteristics in patients with a pulmonologist-confirmed working diagnosis of COPD or ACO.

Patients and Methods

This retrospective cross-sectional study used real-life data (collected between 2007 and 2017) from a Dutch asthma/COPD-service, a structured web-based system in which pulmonologists support general practitioners in their diagnosis of patients with suspicion of obstructive lung disease. The prevalence of asthma characteristics (history of asthma, atopy, symptoms, and reversibility) and blood eosinophil (Eos) counts were assessed in patients with a working diagnosis of COPD or ACO.

Results

Of the 14,141 patients, ≥40 years in the dataset, 4475 (31.6%) were diagnosed with asthma, 3532 (25.0%) with COPD, and 1276 (9.0%) with ACO. Asthma characteristics were present in 65.6% (n=1956) of the COPD and 90.9% (n=1059) of the ACO patients. Eos counts of ≥ 300 cells per μL were found in 35.7% (n=924) of the COPD patients and 35.3% (n=341) of the ACO patients.

Conclusion

In this group of COPD and ACO patients remotely diagnosed by pulmonologists, a substantial proportion would be considered to have asthma characteristics according to the guidelines. This may explain the high number of inhaled corticosteroid (ICS) prescriptions found in primary care COPD patients. Prospective studies are necessary to identify patients who may or may not benefit from ICS containing treatment. Hence, personalized care in primary care can be optimized.

Identification of Asthma-COPD Overlap, Asthma, and Chronic Obstructive Pulmonary Disease Phenotypes in Patients with Airway Obstruction: Influence on Treatment Approach

BACKGROUND

Many studies have described asthma-COPD overlap (ACO) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD), but less so in broad populations of patients with chronic airway obstruction.

OBJECTIVE

This study aimed to (i) examine the prevalence of ACO, asthma, and COPD phenotypes among subjects referred for pulmonary function testing (PFT), who had airway obstruction in spirometry (forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC] <0.7); and (ii) delineate the therapeutic approach of each group.

METHODS

Cross-sectional study of patients who were referred for PFT at the Rokach Institute, in Jerusalem. Working definitions were as follows: (a) COPD: post-bronchodilator (BD) FEV1/FVC <0.70; (b) asthma: physician-diagnosed asthma before age 40 and/or minimum post-BD increase in FEV1 or FVC of 12% and 200 mL; and (c) ACO: the combination of the 2. Demographics, smoking habits, episodes of exacerbation, health-related quality of life (HRQL), and respiratory medication utilization were analyzed.

RESULTS

Of 3,669 referrals from January 1 to April 30, 2017, 1,220 had airway obstruction of which 215 were included. Of these, 82 (38.1%) had ACO, 49 (22.8%) asthma, and 84 (39.1%) COPD. ACO subjects tended to (a) be predominantly female; (b) be older than asthmatics, (c) be smokers; (d) have worse HRQL in the activity domain; and (d) have more exacerbations. Treatment of ACO and COPD patients differed from that of asthmatics, but not from each other, in the proportion of subjects on maintenance treatment, use of LABA, LAMA, and ICS, alone or in combination, and in the number of inhaler devices used by patients.

CONCLUSION

ACO represented >1/3 of patients referred for PFT. Despite a clearly identifiable phenotype, ACO patients received treatment similar to COPD patients, suggesting poor ACO identification. Our data emphasize the need to raise the awareness of ACO among clinicians, in order to guide better recognition and appropriate treatment in individual patients.