Real-world management of chronic obstructive pulmonary disease (COPD) often does not follow Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommendations, resulting in excessive use of inhaled corticosteroids, researchers reported in BMC Pulmonary Medicine.
Researchers conducted a real-world study to examine how patients with COPD were divided into groups (A, B, C, and D) based on the 2017 GOLD guidelines, clinician adherence to GOLD treatment recommendations, the real-world rates of ICS usage and triple therapy (TT) prescription. The retrospective study involved patients of a nonacademic pulmonary specialty practice aged 40 years and older with physician-diagnosed COPD whose records were screened for inclusion between January 1, 2018, and December 31, 2020.
The study population included 1438 patients (mean [SD] age, 69.6 [10.9] years; 52% female; 84% White) who had received therapy for at least 12 months. The patients were classified into groups A, B, C, and D based on the 2017 GOLD guidelines. The ABCD system includes assessment of symptoms with the modified Medical Research Council dyspnea scale or the COPD Assessment Test (CAT), as well as the assessment of exacerbation history in the previous year.
Regarding GOLD stages, 51% of the participants were in GOLD 2, 20.6% were in GOLD 3, and 6.26% were in GOLD 4. The overall average CAT score was 18.3 (99.1). In the ABCD categorization, group B had the most participants (64.05%), followed by group A (19.54%), group D (14.6%), and group C (1.81%).
[T]he reasons for poor adherence to the recommendations by respiratory specialists need to be better understood to provide corrective guidance.
In group A, 18.86% of the patients were treated in concordance with the GOLD COPD 2017 guidelines compared with 26.0% in group B and 91.9% in group D.
Monotherapy with a long-acting β2 agonist (LABA) was used by about 7% to 8% of participants in groups A, B, and C. The combination of LABA + long-acting muscarinic antagonist (LAMA) was used mostly in group C (34.62%). Use of ICS + LABA was 24.2% in group A and was higher than that in groups C or D and much higher than expected based on the GOLD 2017 treatment guidelines.
ICS were overused by all groups, noted the investigators. Overall, 46% of all participants were receiving triple therapy (TT). By group, TT was prescribed to 30.6% of patients in group A, 47.8% in group B, 30.8% in group C, and 63.3% in group D. ICS were used as a part of TT or combined with LABA in 56.2% of patients in group A and 67.3% of those in group B.
Among several limitations, the percentage of patients with no exacerbations was determined with patient chart reviews and by searching for the prescription history for antibiotics and steroids used since their last visit. Also, nonpharmacologic management was not evaluated, including smoking cessation, adherence to oxygen, referral for pulmonary rehabilitation, and compliance with vaccinations.
“The awareness of GOLD guidelines among primary care physicians (PCPs) needs to be improved,” commented the study authors. “Notably, the reasons for poor adherence to the recommendations by respiratory specialists need to be better understood to provide corrective guidance. The continual education of all providers (PCP and respiratory specialists) regarding timely diagnosis, timely referral when the diagnosis is in doubt, recommended treatment pathways, and the rationale behind the guidelines is recommended.”