Seventeen-Year Nationwide Trends in Use of Long-acting Bronchodilators and Inhaled Corticosteroids among Adults - A Danish Drug Utilization Study

Risk of Pulmonary Diseases in Osteogenesis Imperfecta in Denmark: A Register-Based Cohort Study

BACKGROUND

Osteogenesis imperfecta (OI) is a rare hereditary disease mainly resulting in reduced or altered collagen type I. Collagen type I is a major constituent of the respiratory system, and normal collagen type I is vital for pulmonary tissue function.

RESEARCH QUESTION

Do patients with OI have increased admission rates resulting from pulmonary diseases compared with the general population?

STUDY DESIGN AND METHODS

This was a register-based nationwide cohort study including all patients with OI in Denmark and a reference population. From January 1, 1995, through December 31, 2018, we evaluated the rates of admissions resulting from asthma, COPD, and pneumonia as well as the use of bronchodilator drugs and antibiotics comparing individuals with OI with the reference population.

RESULTS

We included 862 individuals with OI and 4,283 people from the reference population covering 15,952 and 79,471 person-years of observation, respectively, in the two cohorts. The admissions rate (incidence rate [IR]) was highest in female patients with OI aged 65 years or older, with 56.3 admissions per 1,000 person-years and 29.4 admissions per 1,000 person-years in the reference population (amounting to an admissions incident rate ratio [IRR] of 1.91 [95% CI, 1.38-2.70]). The highest admission rate in male patients with OI was found among participants aged 0 to 18 years, with an IR of 30.4 per 1,000 person-years compared with an IR of 7.7 per 1,000 person-years in the reference population (IRR, 4.92 [95% CI, 3.79-6.38]). We found a higher proportion of long-acting and short-acting bronchodilator drug users in the OI cohort, but no increased use of antibiotics.

INTERPRETATION

Overall, the admission rates for respiratory diseases were low in the OI cohort, but a higher relative risk of hospitalizations resulting from respiratory disease compared with the general population. Timely diagnosis and treatment of respiratory complications in individuals with OI is warranted.

Inhaled corticosteroid treatment and pneumonia in patients with chronic obstructive pulmonary disease - nationwide development from 1998 to 2018

Background

A decreasing use of inhaled corticosteroids (ICS) in patients with a hospital-registered diagnosis of chronic obstructive pulmonary disease (COPD) has recently been documented in Denmark. ICS treatment is not recommended in patients with high pneumonia risk, and we aimed to assess the development of ICS treatment in relation to pneumonia occurrence.

Methods

Annual nationwide register-based cross-sectional studies from 1998 to 2018 including all patients ≥40 years of age with a hospital-registered ICD-10 diagnosis of COPD on the 31st of December each year. We calculated the annual proportion of patients with at least one outpatient pneumonia (redeemed prescription of relevant antibiotics) or pneumonia hospitalization (hospitalization or ER visit), and stratified by ICS dose (No ICS, low dose, medium dose, or high dose).

Results

The study population increased from 35,656 patients in 1998 to 99,057 patients in 2018. The annual proportion of patients experiencing a pneumonia decreased from 69.4% to 55.2%. The proportion of patients with at least one outpatient pneumonia, but no hospitalization, decreased (59.2% to 46.2%). The overall proportion of patients with at least one pneumonia hospitalization remained unchanged (10.2% to 9.0%), but this proportion increased in patients in high dose ICS (9.9% to 14.6%). The overall proportion of patients in high dose treatment decreased (12.7% to 5.7%), but not in patients with pneumonia hospitalization (16.5% to 15.1).

Conclusions

Our study demonstrates a nationwide decrease from 1998 to 2018 in the proportion of patients who redeemed a prescription for antibiotics used mainly for respiratory tract infections, which may reflect a decrease in the number of outpatient pneumonias. This decrease was largely caused by an increase in the number of patients without pneumonia. No differences over time were seen regarding hospitalization-requiring pneumonia. High dose ICS treatment was unchanged in patients with hospitalization-requiring pneumonia.

Urban-rural and socio-economic differences in inhaled corticosteroid treatment for chronic obstructive pulmonary disease: A nationwide register-based cross-sectional study

BACKGROUND

Urban-rural disparities within chronic obstructive pulmonary disease (COPD) have been documented in USA, but not in Europe. Inhaled corticosteroids (ICS) are widely used in COPD despite strict recommendations. We aimed to investigate urban-rural and socioeconomic differences in ICS treatment for COPD.

METHODS

A Danish nationwide register-based cross-sectional study. All patients alive on the December 31, 2018 with a J44 ICD-10 diagnosis code (COPD) were included (99,057 patients). Daily average ICS dose was calculated from the accumulated ICS use during 2018 based on redeemed prescriptions. Patients were divided into groups: No ICS, low dose ICS, medium dose ICS, high dose ICS. A multinomial logistic regression model including educational level, co-habitation status, age, and sex was performed with "No ICS" as reference group.

RESULTS

Compared to capital municipalities, living in other municipality types was associated with an increased probability of receiving medium and high dose ICS treatment, and increasing odds ratios (ORs) were seen with increasing ICS dose (medium dose ICS: ORs between 1.31 (95 % confidence interval (CI) 1.24-1.38) and 1.35 (95%CI 1.28-1.41), high dose ICS: ORs between 1.73 (95%CI 1.59-1.88) and 1.80 (95%CI 1.68-1.92)). Patients had increased probability of receiving ICS treatment if they were female, were co-habiting, or had completed only primary education.

CONCLUSION

Patients with a hospital-registered COPD diagnosis in non-capital municipalities receive more ICS, and in higher doses, compared to patients in capital municipalities. This is the first study to confirm that such urban-rural differences exist in Europe, and further research on this area is warranted.

National Development in the Use of Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease: Repeated Cross-Sectional Studies from 1998 to 2018

Recommendations for the treatment of chronic obstructive pulmonary disease (COPD) have shifted towards a more restrictive use of inhaled corticosteroids (ICS). We aimed to identify the nationwide development over time in the use of ICS treatment in COPD. We conducted a register-based repeated cross-sectional study using Danish nationwide registers. On a yearly basis from 1998 to 2018, we included all patients in Denmark ≥ 40 years of age with an ICD-10 diagnosis of COPD (J44). Accumulated ICS use was calculated for each year based on redeemed prescriptions. Patients were divided into the following groups: No ICS, low-dose ICS, medium-dose ICS, or high-dose ICS. From 1998 to 2018, the yearly proportion of patients without ICS treatment increased (from 50.6% to 57.6%), the proportion of patients on low-dose ICS treatment increased (from 11.3% to 14.9%), and the proportion of patients on high-dose ICS treatment decreased (from 17.0% to 9.4%). We demonstrated a national reduction in the use of ICS treatment in COPD from 1998 to 2018, with an increase in the proportion of patients without ICS and on low-dose ICS treatment and a decrease in the proportion of patients on high-dose ICS treatment.

Evaluation of drug deliveries and refunds for obstructive airway diseases in France between 2012 and 2017

BACKGROUND

The aim of this survey was to investigate variations of drugs for obstructive airway diseases delivery rates and refunds at a national level which are rarely reported.

METHODS

The French national health data system (56 million, 87% of the population) was used to identify insurance beneficiaries with at least one drug delivery (Anatomical Therapeutic Classification R03) per year between 2012 and 2017.

RESULTS

At least one drug delivery in 2017 was identified for 7.5 million people (12.9%). High proportions of people with at least one, two or three drug deliveries were observed between the ages of 0 to 2 years (22%, 10%, 5.5%), then decreased between the ages of 18 and 40 years (9.3%, 3.8%, 2.3%) and increased again in people 75 years and older (17.8%, 11.9% 9.9%), with strong variations between years. In 2017, the proportions of people with at least one delivery, either alone or in combination with other drugs, were 68% for inhaled corticosteroids (ICS) (median 1; IQR 1-4), 59% for short-acting beta2-agonists (SABA) (1; 1-3), 42% for long-acting beta2-agonists (LABA) (2; 1-6), 11% for leukotriene receptor antagonists (3; 1-9), and 12% for inhaled anti-cholinergics (4; 1-10). Younger patients more often received SABAs (0-2 years: 84%) and leukotriene receptor antagonists (3-6 years: 14%) and people 75 years and older more often received LABAs (59%) and ICS, either alone or in combination with other drugs (28%).The mean annual refund reimbursed per person decreased from €136 in 2012 to €118 in 2017.

CONCLUSION

This study suggests a low level of use for drug classes associated with low delivery rates, suggesting inappropriate prescriptions and poor follow-up. These results highlight the difficulty of identifying these problems if delivery rates variations over several years are not taken into account.

Is the Disease Burden from COPD in Norway Falling off? A Study of Time Trends in Three Different Data Sources

Background

Less smoking should lead to fewer COPD cases. We aimed at estimating time trends in the prevalence and burden of COPD in Norway from 2001 to 2017.

Methods

We used pre-bronchodilator spirometry and other health data from persons aged 40–84 years in three surveys of the Tromsø Study, 2001–2002, 2007–2008 and 2015–2016. We applied spirometry lower limits of normal (LLN) according to Global Lung Initiative 2012. Age-standardized prevalence was determined. We defined COPD as FEV₁/FVC<LLN in subjects reporting dyspnea or coughing, and moderate to severe COPD when FEV₁ <LLN was found in addition. We identified hospitalizations due to COPD exacerbations in the Norwegian Patient Registry 2010–2017, and retrieved the use of COPD medication from the Norwegian Prescription Database. Change in prevalence was analyzed by logistic regression.

Results

In the Tromsø Study, the age-standardized prevalence of daily smoking dropped from 29.9% to 14.1% among women and from 31.4% to 12.8% among men (P<0.0001). The age-standardized prevalence of COPD dropped from 7.6% to 5.6% among women (P=0.2) and from 7.3% to 5.6% among men (P=0.003) and of moderate to severe COPD from 5.2% to 2.7% among women (P=0.0003) and from 4.6% to 3.2% among men (P=0.0008). Among men, the yearly age-standardized prevalence of hospitalization due to COPD exacerbation decreased from 3.6 to 3.0 per 1000 inhabitants aged 40–84 years (P<0.0001). Correspondingly, dispensing oral corticosteroids or/and antibiotics for COPD exacerbations dropped from 6.6 to 5.8 per 1000 (P<0.0001), while dispensing maintenance treatment increased (P<0.0001).

Conclusion

COPD morbidity decreased between 2001 and 2017, which might partly be due to less smoking. The drop in smoking prevalence gives promise of a further substantial decrease in the coming decades.

Polypharmacy among Older Individuals with COPD: Trends between 2000 and 2015 in Quebec, Canada

The treatment of chronic obstructive pulmonary disease (COPD) and concomitant diseases requires several medications. Yet there is little data on how the pharmacological burden progressed over time among older individuals with COPD. We aimed to: 1) describe the proportion of older adults with COPD in Quebec, Canada, that were exposed to polypharmacy (≥10, ≥15 or ≥20 medications/year) between 2000 and 2015; 2) calculate the proportion of individuals receiving specific prescriptions for COPD during this period. We conducted a population-based cohort study with the Quebec Integrated Chronic Disease Surveillance System. Individuals aged ≥66 years with COPD and covered by the universal public drug plan were included. We calculated the total number of drugs used at least once by each individual during each of the studied years, and used age-standardized proportions to compare proportions of users between the years. The average number of drugs used increased from 12.0 in 2000 to 14.8 in 2015. The proportion of individuals exposed to polypharmacy increased (≥10 drugs: 62.0% to 74.6%;≥15 drugs: 31.2% to 45.4%; ≥20 drugs: 12.3% to 22.4%). The proportion of individuals receiving long-acting bronchodilators increased from 18.7% in 2000 to 69.6% in 2015. The use of short-acting bronchodilators decreased from 81.5% to 67.9%, and that of inhaled corticosteroids from 60.6% to 26.0%. The proportion of users of methylxanthines decreased from 15.0% to 1.9%. Older individuals with COPD are increasingly exposed to polypharmacy. Identifying which polypharmacy is beneficial is a priority.

Nationwide use of theophylline among adults-A 20-year Danish drug utilisation study

BACKGROUND

Theophylline, a dimethylxanthine, has been used the last 100 years to treat airway disease. Although it is one of the most widely prescribed medicines to treat asthma and chronic obstructive pulmonary disease (COPD) throughout the years, the utilisation patterns are not well-described.

METHODS

Using the Danish Register of Medicinal Products Statistics, we identified adults above 18 years redeeming one or more prescriptions of theophylline between 1997 up to 2017, with a 2-year run-in period from 1995 to 1997. Using descriptive statistics, we reported the development in prevalence, incidence, and a measure of treatment duration (proportion of patients covered).

RESULTS

In total, 55,636 individuals redeemed 1,066,475 prescriptions of theophylline, 30,619 women (55%) and 25,017 men (45%). The prevalence decreased from 401 per 100,000 individuals in 1997 to 26 per 100,000 individuals in 2016. The incidence rate decreased throughout the entire study period (105 per 100,000 person-years in 1997 to 5 per 100,000 person-years in 2016). In total, 52% were still current users three months after theophylline initiation, 33%, 27%, and 23% were current users after 6 months, one year, and two years.

CONCLUSIONS

Although newer and more efficient medicines to treat asthma and COPD has been developed, theophylline is still prescribed and used in 2016, but the incidence and prevalence have decreased markedly since 1997.