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

Abstract

Purpose

Inappropriate use of an inhaled corticosteroid (ICS) for COPD has clinical and economic disadvantages. This retrospective analysis of The UK Health Improvement Network (THIN) database identified factors influencing treatment escalation (step-up) from a long-acting muscarinic antagonist (LAMA) to triple therapy (LAMA + long-acting β-agonist-ICS). Secondary objectives included time to step up from first LAMA prescription, Global Initiative for Chronic Obstructive Lung Disease (GOLD) grouping (2011/2013, 2017), and Medical Research Council (MRC) grade prior to treatment escalation.

Materials and methods

Data were included from 14,866 people ≥35 years old with a COPD diagnosis (June 1, 2010–May 10, 2015) and initiated on LAMA monotherapy. The most commonly used LAMA at baseline was tiotropium (92%).

Results

Multivariate analysis (10,492 patients) revealed that COPD exacerbations, lower forced expiratory volume in 1 second (FEV₁), “asthma”, MRC grade, proactive and reactive COPD primary care, elective secondary-care contact, cough, and number of short-acting bronchodilator prescriptions were positively associated with treatment escalation (P<0.05). Being older, a current/ex-smoker, or having increased sputum symptom codes were negatively associated with treatment escalation (P<0.05). Median MRC score was 2 at baseline and 3 prior to treatment escalation. Using the last MRC reading and exacerbation history in the year prior to escalation, GOLD 2017 groupings were A 27.4%, B 37.3%, C 15.3%, and D 20%. In patients with available FEV₁ measures, exacerbations, and MRC code (n=1,064), GOLD 2011/2013 groupings were A 20.4%, B 19.2%, C 24.8%, and D 35.6%.

Conclusion

While the presence of COPD exacerbations seems to be the main driver for treatment escalation, according to the 2017 GOLD strategy many patients appear to be overtreated, as they would not be recommended for treatment escalation. Reviewing patients’ treatment in the light of the new GOLD strategy has the potential to reduce inappropriate use of triple therapy.

Keywords:

• inhaled corticosteroid
• treatment step-up
• GOLD 2017 grouping
• patient overtreatment

Supplementary material

Table S1 Covariates during the analyzed baseline period

Acknowledgments

This study was sponsored by Pfizer. The authors would like to thank Ewa Śleszyńska-Dopiera of Quanticate Ltd for her programming support. Medical writing support was provided by Helen Jones and Karen Burrows of Engage Scientific Solutions and was funded by Pfizer.

Disclosure

JRH reports personal fees for advisory boards and educational activities and support to attend meetings from pharmaceutical companies that make medicines to treat COPD. MD, SH, and BE are employees of Pfizer and have company stock/shares. KM was an employee of Pfizer at the time of study conduct. RJ reports no conflicts of interest in relation to this study, but reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GSK, Novartis, and Pfizer. The authors report no other conflicts of interest in this work.