The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK

Guy Brusselle,1–3 David Price,4,5 Kevin Gruffydd-Jones,6 Marc Miravitlles,7 Dorothy L Keininger,8 Rebecca Stewart,5 Michael Baldwin,9 Rupert C Jones101Department of Respiratory Medicine, University Hospital Ghent, Ghent, Belgium; 2Department of Epidemiology, 3Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, Netherlands; 4Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK; 5Research in Real Life (RiRL), Singapore; 6Box Surgery, Wiltshire, UK; 7Pneumology Department, Hospital Universitari Vall d’Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; 8Novartis Pharma AG, Basel, Switzerland; 9Novartis Pharmaceuticals Limited, Horsham, UK; 10Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKBackground: Real-world prescription pathways leading to triple therapy (TT) (inhaled corticosteroid [ICS] plus long-acting β2-agonist bronchodilator [LABA] plus long-acting muscarinic antagonist) differ from Global initiative for chronic Obstructive Lung Disease [GOLD] and National Institute for Health and Care Excellence treatment recommendations. This study sets out to identify COPD patients without asthma receiving TT, and determine the pathways taken from diagnosis to the first prescription of TT.Methods: This was a historical analysis of COPD patients without asthma from the Optimum Patient Care Research Database (387 primary-care practices across the UK) from 2002 to 2010. Patient disease severity was classified using GOLD 2013 criteria. Data were analyzed to determine prescribing of TT before, at, and after COPD diagnosis; the average time taken to receive TT; and the impact of lung function grade, modified Medical Research Council dyspnea score, and exacerbation history on the pathway to TT.Results: During the study period, 32% of patients received TT. Of these, 19%, 28%, 37%, and 46% of patients classified as GOLD A, B, C, and D, respectively, progressed to TT after diagnosis (P<0.001). Of all patients prescribed TT, 25% were prescribed TT within 1 year of diagnosis, irrespective of GOLD classification (P=0.065). The most common prescription pathway to TT was LABA plus ICS. It was observed that exacerbation history did influence the pathway of LABA plus ICS to TT.Conclusion: Real life UK prescription data demonstrates the inappropriate prescribing of TT and confirms that starting patients on ICS plus LABA results in the inevitable drift to overuse of TT. This study highlights the need for dissemination and implementation of COPD guidelines to physicians, ensuring that patients receive the recommended therapy.Keywords: chronic obstructive pulmonary disease, GOLD guidelines, observational study, prescribing patterns, primary car