A Real-World Analysis of Treatment Patterns and Clinical Characteristics Among Patients with COPD Who Initiated Multiple-Inhaler Triple Therapy in New Zealand

Figures & data

Figure 1 Study design.

Abbreviation: MITT, multiple-inhaler triple therapy.

Table 1 Definitions of Treatments for COPD That Were Recorded Across the Study Period (1 January 2014 to 30 April 2018)

Treatment Type	Category	Treatment Description	Definition of Prescription
Monotherapy	LABA	Monotherapy in one device	LABA prescription that never overlaps with an ICS or LAMA prescription
	LAMA	Monotherapy in one device	LAMA prescription that never overlaps with an ICS, LABA, or ICS/LABA prescription
	ICS	Monotherapy in one device	ICS prescription that never overlaps with a LAMA, LABA, or LAMA/LABA prescription
Dual therapy	LABA and LAMA^a	Open combination therapy in two devices	LABA prescription that overlaps by ≥1 day with a LAMA prescription and which does not overlap with an ICS prescription OR LAMA prescription that overlaps by ≥1 day with a LABA prescription and which does not overlap with an ICS prescription
	LAMA^a and ICS	Open combination therapy in two devices	LAMA prescription that overlaps by ≥1 day with an ICS prescription and which does not overlap with a LABA prescription OR ICS prescription that overlaps by ≥1 day with a LAMA prescription and which does not overlap with a LABA prescription
	LABA and ICS	Fixed combination therapy in one device OR Open combination therapy in two devices	Fixed combination ICS/LABA prescription OR LABA prescription that overlaps by ≥1 day with an ICS prescription and which does not overlap with a LAMA prescription
Triple therapy	ICS, LAMA, and LABA	Fixed combination ICS/LABA therapy in one device plus LAMA monotherapy OR Fixed combination LAMA/LABA therapy in one device plus ICS monotherapy OR Open combination ICS+LAMA+LABA therapy in three devices	Fixed combination ICS/LABA prescription that overlaps by ≥1 day with a LAMA prescription OR Fixed combination LAMA/LABA that overlaps by ≥1 day with an ICS prescription OR LAMA prescription that overlaps by ≥1 day with an ICS prescription and a LABA prescription OR LABA prescription that overlaps by ≥1 day with an ICS prescription and a LAMA prescription OR ICS prescription that overlaps by ≥1 day with a LABA prescription and a LAMA prescription

Note: ^aCurrently only represented by tiotropium.

Abbreviations: COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting β₂agonist; LAMA, long-acting muscarinic antagonist.

Figure 2 Diagram showing the calculation of MPR.

Abbreviations: MITT, multiple-inhaler triple therapy; MPR, Medical Possession Ratio.

Figure 3 PDC definition when considering overlap of all three triple therapy components (A); and when considering each triple therapy component separately (B).

Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist; MITT, multiple-inhaler triple therapy; PDC, proportion of days covered.

Figure 4 Flow chart of patient disposition.

Abbreviations: COPD, chronic obstructive pulmonary disease; MITT, multiple-inhaler triple therapy.

Table 2 Baseline Demographics and Clinical Characteristics of Patients with COPD Who Initiated MITT Between 1 May 2016 and 30 April 2017

	Total (N=421)
Age, years
Mean ± SD	67.3 ± 11.0
Median (IQR)	67.4 (15.7)
Age groups, n (%)
40–49	26 (6.2)
50–59	87 (20.7)
60–69	129 (30.6)
70–79	124 (29.5)
≥80	55 (13.1)
Male, n (%)	190 (45.1)
Inhalers prescribed for MITT, n (%)
2	416 (98.8)
3	5 (1.2)
Ethnicity, n (%)
European	288 (68.4)
Māori	110 (26.1)
Pacific	11 (2.6)
Asian	9 (2.1)
Other	3 (0.7)
Smoking status, n (%)^a,b
Smoker	228 (54.2)
Ex-smoker	149 (35.4)
Non-smoker	38 (9.0)
Prior COPD exacerbations, n (%)
None	129 (30.6)
1	114 (27.1)
≥2	178 (42.3)
Mean (SD) number of COPD exacerbations
All	1.8 (2.0)
Moderate	1.7 (2.0)
Severe	0.2 (0.6)
Median (IQR) number of COPD exacerbations
All	1 (3.0)
Moderate	1 (3.0)
Severe	0 (0.0)
Comorbidities, n (%)
Asthma	179 (42.5)
Ischemic heart disease	84 (20.0)
Diabetes mellitus	85 (20.2)
Heart failure	63 (15.0)
Stroke	34 (8.1)
Mental conditions	145 (34.4)
BMI, kg/m^2a
Mean ± SD	29.5 ± 7.9
Median (IQR)	28.0 (10.2)
BMI category, n (%)^a
Normal	103 (24.5)
Obese	165 (39.2)
Overweight	112 (26.6)
Underweight	19 (4.5)
Unknown	22 (5.2)

Notes: ^aCalculated using data from 30 April 2018; ^bN=415.

Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; IQR, interquartile range; MITT, multiple-inhaler triple therapy; SD, standard deviation.

Table 3 Treatment Class and Median Treatment Duration in 12 Months Prior to MITT Initiation

	n (%)	Median (IQR) Treatment Duration, Days
All patients	421 (100.0)	350 (262.0)
Treatment prior to MITT initiation
ICS	11 (2.6)	166 (309.0)
LABA	3 (0.7)	92 (347.0)
LAMA	31 (7.4)	93 (184.0)
ICS/LABA	249 (59.1)	323 (239.0)
LAMA+LABA	12 (2.9)	92 (100.5)
ICS+LAMA	17 (4.0)	365 (275.0)
None	98 (23.3)	365 (148.0)

Abbreviations: ICS, inhaled corticosteroid; IQR, interquartile range; LABA, long-acting β-agonist; LAMA, long-acting muscarinic antagonist; MITT, multiple-inhaler triple therapy.

Table 4 Treatment Patterns Among Patients with COPD Who Initiated MITT Between 1 May 2016 and 30 April 2017

Treatment Pattern	Outcome	All Patients Initiating MITT (N=421)	Index MITT Treatment
			ICS/LABA + LAMA (N=394)	Other^a (N=27)
No modification (N=141)	Continuous use of index treatment, n (%)	141 (33.5)	137 (34.8)	4 (14.8)
Modification of index MITT treatment (N=280)	Direct switch to another MITT, n (%)	105 (24.9)	94 (23.9)	11 (40.7)
	Retreatment with MITT, n (%)	57 (13.5)	53 (13.5)	4 (14.8)
	Step down, n (%)	83 (19.7)	110 (27.9)	8 (29.6)
	ICS	3 (0.7)	1 (0.3)	2 (7.4)
	LABA	2 (0.5)	0 (0.0)	2 (7.4)
	ICS and LABA^b	33 (7.8)	33 (8.4)	0 (0.0)
	LAMA and LABA^c	17 (4.0)	14 (3.6)	3 (11.1)
	LAMA	27 (6.4)	27 (6.9)	0 (0.0)
	ICS and LAMA^d	1 (0.2)	0 (0.0)	1 (3.7)
	Discontinuation, n (%)	35 (8.3)	35 (8.9)	0 (0.0)
	Time to first treatment modification, days
	Mean (SD)	144.4 (87.7)	146.7 (88.1)	119.4 (80.5)
	Median (IQR)	150.0 (108.0)	150.0 (112.0)	101.0 (88.0)

Notes: ^aIncludes patients who initiated MITT on ICS+LAMA/LABA (n=22) and ICS + LAMA+LABA (n=5), which were not analyzed further due to small sample size; ^bIncludes both ICS/LABA and ICS+LABA; ^cIncludes both LAMA/LABA and LAMA+LABA; ^dICS+LAMA only.

Abbreviations: COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; IQR, interquartile range; LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist; MITT, multiple-inhaler triple therapy; SD, standard deviation.

Table 5 Persistence and Adherence for Patients with COPD Who Initiated MITT Between 1 May 2016 and 30 April 2017

N=421	Mean (SD)	Median (IQR)	Adherence^a, n (%)
Persistence^b to MITT
3-month period after initiation	91.4 (28.0)	NE	NE
6-month period after initiation	63.2 (48.3)	NE	NE
12-month period after initiation	47.3 (50.0)	NE	NE
MPR	75.9 (22.7)	80.3 (33.0)	225 (53.4)
PDC with overlap of all three MITT components
3-month period after initiation	97.0 (11.8)	100.0 (0.0)	397 (94.3)
6-month period after initiation	89.6 (18.5)	100.0 (17.6)	364 (86.5)
12-month period after initiation	77.9 (28.3)	97.8 (51.2)	265 (62.9)
PDC with individual components of MITT
3-month period after initiation	99.7 (0.5)	100.0 (1.1)	421 (100.0)
6-month period after initiation	91.0 (15.7)	98.9 (8.8)	200 (47.5)
12-month period after initiation	85.9 (19.5)	94.5 (17.8)	321 (76.2)

Notes: ^aMPR or PDC ratio ≥80%; ^bPersistence was defined as continuous medication use without a gap of 60 days in any of the three components of MITT (ie, ICS, LAMA, or LABA).

Abbreviations: COPD, chronic obstructive pulmonary disease; IQR, interquartile range; MITT, multiple-inhaler triple therapy; MPR, medication possession ratio; NE, not evaluated; PDC, proportion of days covered; SD, standard deviation.