Prescription Pathways from Initial Medication Use to Triple Therapy in Older COPD Patients: A Real-World Population Study

Abstract

Background and objective

Triple therapy with an inhaled corticosteroid (ICS), a long-acting β₂-agonist bronchodilator (LABA) and a long-acting muscarinic antagonist (LAMA) is recommended as step-up therapy for chronic obstructive pulmonary disease (COPD) patients who continue to have persistent symptoms and increased risk of exacerbation despite treatment with dual therapy. We sought to evaluate different treatment pathways through which COPD patients were escalated to triple therapy.

Methods

We used population health databases from Ontario, Canada to identify individuals aged 66 or older with COPD who started triple therapy between 2014 and 2017. Median time from diagnosis to triple therapy was estimated using the Kaplan-Meier method. We classified treatment pathways based on treatments received prior to triple therapy and evaluated whether pathways differed by exacerbation history, blood eosinophil counts or time period.

Results

Among 4108 COPD patients initiating triple therapy, only 41.2% had a COPD exacerbation in the year prior. The three most common pathways were triple therapy as initial treatment (32.5%), LAMA to triple therapy (29.8%), and ICS + LABA to triple therapy (15.4%). Median time from diagnosis to triple therapy was 362 days (95% confidence interval:331–393 days) overall, but 14 days (95% CI 12–17 days) in the triple therapy as initial treatment pathway. This pathway was least likely to contain patients with frequent or severe exacerbations (22.0% vs. 31.5%, p < 0.001) or with blood eosinophil counts ≥300 cells/µL (18.9% vs. 22.0%, p < 0.001).

Conclusion

Real-world prescription of triple therapy often does not follow COPD guidelines in terms of disease severity and prior treatments attempted.

Keywords:

• COPD
• medication
• management

Acknowledgements

This study was supported by ICES (formerly the Institute for Clinical Evaluative Sciences), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information. Parts of this material are based on data and information compiled and provided by Ontario Ministry of Health (MOH). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. We thank IQVIA Solutions Canada Inc. for use of their Drug Information File.

Disclosure statement

Andrea S. Gershon has received grants from Canadian Institutes of Health Research Foundation Grant during the conduct of the study; Tetyana Kendzerska has received grants from The PSI foundation outside the submitted work; Shawn D. Aaron has received personal fees from Glaxo Smith Kline and Sanofi outside the submitted work; Wan Tan has received grants from Canadian Institute of Heath Research (CIHR/Rx&D Collaborative Research Program Operating Grants- 93326) with industry partners AstraZeneca Canada Ltd., Boehringer-Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Merck, Novartis Pharma Canada Inc., Nycomed Canada Inc., Pfizer Canada Ltd, she has also received personal fees from GlaxoSmith Kline and Astrazeneca outside the submitted work; all other authors declare that they have no conflict of interest.

Funding

This project was funded by Canadian Institutes of Health Research Foundation Grant (Reference Number: 154319). It was also supported by the Canadian Respiratory Research Network. The Canadian Respiratory Research Network is supported by grants from the Canadian Institutes of Health Research (CIHR)-Institute of Circulatory and Respiratory Health; Canadian Lung Association/Canadian Thoracic Society; British Columbia Lung Association; and Industry Partners Boehringer-Ingelheim Canada Ltd, AstraZeneca Canada Inc., and Novartis Canada Ltd.

Data availability statement

The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g. healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: [email protected]). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.