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      Factors influencing pharmacological treatment in COPD: a comparison of 2005 and 2014

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          ABSTRACT

          Introduction: The aim was to investigate how the pattern of pharmacological treatment in Swedish patients with chronic obstructive pulmonary disease (COPD) has changed over a decade, and to identify factors associated with treatment.

          Methods: Data on patient characteristics and pharmacological treatment were collected using questionnaires from two separate cohorts of randomly selected primary and secondary care patients with a doctor’s diagnosis of COPD in central Sweden, in 2005 ( n = 1111) and 2014 ( n = 1329). Cross-tabulations and chi-square tests were used to compare maintenance treatment in 2005 and 2014, and to investigate the distribution of treatment by the 2017 Global Initiative for Obstructive Lung Disease (GOLD) ABCD groups. Multinomial logistic regression was used to analyze associations with the major types of recommended treatments: bronchodilator therapy, combined long-acting beta-2-antagonists (LABA) + inhaled corticosteroids (ICS), and triple inhaled therapy.

          Results: The proportion of patients with no maintenance treatment, with only LABA + ICS, and with sole ICS statistically significantly decreased (36 vs. 31%, 16 vs. 12% and 5 vs. 2%, respectively), and the proportion with triple inhaled therapy statistically significantly increased (29 vs. 40%). In 2014, triple inhaled therapy was the most common treatment in all GOLD groups except group A. In 2014, previous frequent exacerbations [OR (95% CI) 2.34 (1.62 to 3.36)], worse COPD Assessment Test score [1.07 (1.05 to 1.09)], female sex [2.13 (1.56 to 2.91)], and access to a specific responsible doctor [1.95 (1.41 to 2.69)] were associated with triple inhaled therapy. Current smoking [0.40 (0.28 to 0.57)] and overweight [0.62 (0.41 to 0.93)] were inversely associated with triple inhaled therapy.

          Conclusions: Over the last decade, triple inhaled therapy has increased, and no maintenance treatment, ICS, or LABA + ICS has decreased. Triple inhaled therapy is the most common treatment and is associated with previous exacerbations, higher symptom level, female sex, and having a specific responsible doctor.

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          Most cited references36

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          Development and first validation of the COPD Assessment Test.

          P W Jones, G. Harding, P. Berry … (2009)
          There is need for a validated short, simple instrument to quantify chronic obstructive pulmonary disease (COPD) impact in routine practice to aid health status assessment and communication between patient and physician. Current health-related quality of life questionnaires provide valid assessment of COPD, but are complex, which limits routine use. The aim of the present study was to develop a short validated patient-completed questionnaire, the COPD Assessment Test (CAT), assessing the impact of COPD on health status. 21 candidate items identified through qualitative research with COPD patients were used in three prospective international studies (Europe and the USA, n = 1,503). Psychometric and Rasch analyses identified eight items fitting a unidimensional model to form the CAT. Items were tested for differential functioning between countries. Internal consistency was excellent: Cronbach's alpha = 0.88. Test re-test in stable patients (n = 53) was very good (intra-class correlation coefficient 0.8). In the sample from the USA, the correlation with the COPD-specific version of the St George's Respiratory Questionnaire was r = 0.80. The difference between stable (n = 229) and exacerbation patients (n = 67) was five units of the 40-point scale (12%; p<0.0001). The CAT is a short, simple questionnaire for assessing and monitoring COPD. It has good measurement properties, is sensitive to differences in state and should provide a valid, reliable and standardised measure of COPD health status with worldwide relevance.
          Article 0 comments Cited 516 times – based on 0 reviews     Review now
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            Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.

            J C Bestall, E Paul, R. Garrod … (1999)
            Methods of classifying chronic obstructive pulmonary disease (COPD) depend largely upon spirometric measurements but disability is only weakly related to measurements of lung function. With the increased use of pulmonary rehabilitation, a need has been identified for a simple and standardised method of categorising disability in COPD. This study examined the validity of the Medical Research Council (MRC) dyspnoea scale for this purpose. One hundred patients with COPD were recruited from an outpatient pulmonary rehabilitation programme. Assessments included the MRC dyspnoea scale, spirometric tests, blood gas tensions, a shuttle walking test, and Borg scores for perceived breathlessness before and after exercise. Health status was assessed using the St George's Respiratory Questionnaire (SGRQ) and Chronic Respiratory Questionnaire (CRQ). The Nottingham Extended Activities of Daily Living (EADL) score and Hospital Anxiety and Depression (HAD) score were also measured. Of the patients studied, 32 were classified as having MRC grade 3 dyspnoea, 34 MRC grade 4 dyspnoea, and 34 MRC grade 5 dyspnoea. Patients with MRC grades 1 and 2 dyspnoea were not included in the study. There was a significant association between MRC grade and shuttle distance, SGRQ and CRQ scores, mood state and EADL. Forced expiratory volume in one second (FEV1) was not associated with MRC grade. Multiple logistic regression showed that the determinants of disability appeared to vary with the level of disability. Between MRC grades 3 and 4 the significant covariates were exercise performance, SGRQ and depression score, whilst between grades 4 and 5 exercise performance and age were the major determinants. The MRC dyspnoea scale is a simple and valid method of categorising patients with COPD in terms of their disability that could be used to complement FEV1 in the classification of COPD severity.
            Article 0 comments Cited 397 times – based on 0 reviews     Review now
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              Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease.

              Peter M.A. Calverley, Julie Anderson, Bartolome R Celli … (2007)
              Long-acting beta-agonists and inhaled corticosteroids are used to treat chronic obstructive pulmonary disease (COPD), but their effect on survival is unknown. We conducted a randomized, double-blind trial comparing salmeterol at a dose of 50 microg plus fluticasone propionate at a dose of 500 microg twice daily (combination regimen), administered with a single inhaler, with placebo, salmeterol alone, or fluticasone propionate alone for a period of 3 years. The primary outcome was death from any cause for the comparison between the combination regimen and placebo; the frequency of exacerbations, health status, and spirometric values were also assessed. Of 6112 patients in the efficacy population, 875 died within 3 years after the start of the study treatment. All-cause mortality rates were 12.6% in the combination-therapy group, 15.2% in the placebo group, 13.5% in the salmeterol group, and 16.0% in the fluticasone group. The hazard ratio for death in the combination-therapy group, as compared with the placebo group, was 0.825 (95% confidence interval [CI], 0.681 to 1.002; P=0.052, adjusted for the interim analyses), corresponding to a difference of 2.6 percentage points or a reduction in the risk of death of 17.5%. The mortality rate for salmeterol alone or fluticasone propionate alone did not differ significantly from that for placebo. As compared with placebo, the combination regimen reduced the annual rate of exacerbations from 1.13 to 0.85 and improved health status and spirometric values (P<0.001 for all comparisons with placebo). There was no difference in the incidence of ocular or bone side effects. The probability of having pneumonia reported as an adverse event was higher among patients receiving medications containing fluticasone propionate (19.6% in the combination-therapy group and 18.3% in the fluticasone group) than in the placebo group (12.3%, P<0.001 for comparisons between these treatments and placebo). The reduction in death from all causes among patients with COPD in the combination-therapy group did not reach the predetermined level of statistical significance. There were significant benefits in all other outcomes among these patients. (ClinicalTrials.gov number, NCT00268216 [ClinicalTrials.gov].). Copyright 2007 Massachusetts Medical Society.
              Article 0 comments Cited 214 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Eur Clin Respir J
                Journal ID (iso-abbrev): Eur Clin Respir J
                Journal ID (archive): ZECR
                Journal ID (publisher-id): zecr20
                Title: European Clinical Respiratory Journal
                Publisher: Taylor & Francis
                ISSN (Electronic): 2001-8525
                Publication date Collection: 2017
                Publication date (Electronic): 04 December 2017
                Volume: 4
                Issue: 1
                Electronic Location Identifier: 1409060
                Affiliations
                [ a ] Department of Respiratory Medicine, School of Medical Sciences, Örebro University , Örebro, Sweden
                [ b ] School of Medical Sciences, Örebro University , Örebro, Sweden
                [ c ] Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University , Örebro, Sweden
                [ d ] Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet , Stockholm, Sweden
                [ e ] Department of Epidemiology and Public Health, University College , London, UK
                [ f ] Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University , Uppsala, Sweden
                [ g ] Department of Medical Sciences: Respiratory; Allergy and Sleep Research, Uppsala University , Uppsala, Sweden
                Author notes
                CONTACT Josefin Sundh josefin.sundh@ 123456oru.se
                Author information
                http://orcid.org/0000-0003-1926-8464
                http://orcid.org/0000-0003-4241-7851
                http://orcid.org/0000-0001-8497-7326
                Article
                Publisher ID: 1409060
                DOI: 10.1080/20018525.2017.1409060
                PMC ID: 5717719
                SO-VID: 3a585d67-10bd-4caf-9205-59dadc1e7b02
                Copyright © © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 17 July 2017
                Date accepted : 18 November 2017
                Page count
                Figures: 2, Tables: 4, References: 38, Pages: 11
                Funding
                The authors did not receive any grants for this specific study.
                Categories
                Subject: Research Article
                Subject: Original Article

                Keywords: lama,laba,ics,bronchodilator therapy,triple inhaled therapy,symptoms,frequent exacerbations gold 2017
                Data availability:
                Keywords: lama, laba, ics, bronchodilator therapy, triple inhaled therapy, symptoms, frequent exacerbations gold 2017

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