Understanding the People Excluded from Chronic Obstructive Pulmonary Disease Clinical Trials

Comparative effectiveness and safety of single inhaler triple therapies for chronic obstructive pulmonary disease: new user cohort study

OBJECTIVE

To compare the effectiveness and safety of budesonide-glycopyrrolate-formoterol, a twice daily metered dose inhaler, and fluticasone-umeclidinium-vilanterol, a once daily dry powder inhaler, in patients with chronic obstructive pulmonary disease (COPD) treated in routine clinical practice.

DESIGN

New user cohort study.

SETTING

Longitudinal commercial US claims data.

PARTICIPANTS

New initiators of budesonide-glycopyrrolate-formoterol or fluticasone-umeclidinium-vilanterol between 1 January 2021 and 30 September 2023 who had a diagnosis of COPD and were aged 40 years or older.

MAIN OUTCOME MEASURES

In this 1:1 propensity score matched study, the main outcome measures were first moderate or severe COPD exacerbation (effectiveness) and first admission to hospital with pneumonia (safety) while on treatment. Potential confounders were measured in the 365 days before cohort entry and included in propensity scores. Hazard ratios and 95% confidence intervals (CIs) were estimated using a Cox proportional hazards regression model.

RESULTS

The study cohort included 20 388 propensity score matched pairs of new users initiating single inhaler triple therapy. Patients who received budesonide-glycopyrrolate-formoterol had a 9% higher incidence of first moderate or severe COPD exacerbation (hazard ratio 1.09 (95% CI 1.04 to 1.14); number needed to harm 38) compared with patients receiving fluticasone-umeclidinium-vilanterol and an identical incidence of first admission to hospital with pneumonia (1.00 (0.91 to 1.10)). The hazard of first moderate COPD exacerbation was 7% higher (1.07 (1.02 to 1.12); number needed to harm 54) and the hazard of first severe COPD exacerbation 29% higher (1.29 (1.12 to 1.48); number needed to harm 97) among those receiving budesonide-glycopyrrolate-formoterol compared to fluticasone-umeclidinium-vilanterol. Prespecified sensitivity analyses yielded similar findings to the primary analysis.

CONCLUSIONS

Budesonide-glycopyrrolate-formoterol was not associated with improved clinical outcomes compared with fluticasone-umeclidinium-vilanterol. Given the added climate impact of metered dose inhalers, health systems seeking to decrease use of these products may consider steps to promote further prescribing of fluticasone-umeclidinium-vilanterol compared with budesonide-glycopyrrolate-formoterol in people with COPD.

STUDY REGISTRATION

Center for Open Science Real World Evidence Registry (https://osf.io/6gdyp/).

Effects of triple therapy on disease burden in patients of GOLD groups C and D: results from the observational COPD cohort COSYCONET

BACKGROUND

Randomized controlled trials described beneficial effects of inhaled triple therapy (LABA/LAMA/ICS) in patients with chronic obstructive pulmonary disease (COPD) and high risk of exacerbations. We studied whether such effects were also detectable under continuous treatment in a retrospective observational setting.

METHODS

Data from baseline and 18-month follow-up of the COPD cohort COSYCONET were used, including patients categorized as GOLD groups C/D at both visits (n = 258). Therapy groups were defined as triple therapy at both visits (triple always, TA) versus its complement (triple not always, TNA). Comparisons were performed via multiple regression analysis, propensity score matching and inverse probability weighting to adjust for differences between groups. For this purpose, variables were divided into predictors of therapy and outcomes.

RESULTS

In total, 258 patients were eligible (TA: n = 162, TNA: n = 96). Without adjustments, TA patients showed significant (p < 0.05) impairments regarding lung function, quality of life and symptom burden. After adjustments, most differences in outcomes were no more significant. Total direct health care costs were reduced but still elevated, with inpatient costs much reduced, while costs of total and respiratory medication only slightly changed.

CONCLUSION

Without statistical adjustment, patients with triple therapy showed multiple impairments as well as elevated treatment costs. After adjusting for differences between treatment groups, differences were reduced. These findings are compatible with beneficial effects of triple therapy under continuous, long-term treatment, but also demonstrate the limitations encountered in the comparison of controlled intervention studies with observational studies in patients with severe COPD using different types of devices and compounds.