Study: COPD Treatment in China Relies Too Heavily on Inhaled Corticosteroids

People in China with chronic obstructive pulmonary disease (COPD) are overusing inhaled corticosteroids and underusing non-pharmacological therapies such as home oxygen therapy, a study suggests.

The real-world data show that treatment of COPD patients fails to follow the 2017 revised Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.

The study “Current Status of the Treatment of COPD in China: A Multicenter Prospective Observational Study” was published in the International Journal of Chronic Obstructive Pulmonary Disease.

GOLD guidelines are regularly updated and they work as a reference for treating COPD patients worldwide. The 2017 revised GOLD guidelines detail the recommendations for COPD treatment according to disease stage; however, research suggests that what is practiced in the real world might be different.

A group of researchers in China conducted an observational study to assess the therapies given to COPD patients in a real-world setting, and the patients’ prognosis after treatment for one year.

“There is a large gap in the treatments for patients with COPD according to the Global Initiative for COPD (GOLD) recommendations. Determining the situation of therapies in the real world is necessary,” the team wrote.

In total, researchers analyzed data from 4,796 patients with COPD (mean age 64 and 87.7% were men) who were followed at 12 hospitals in China. Almost half (41.5%) were smokers. Data from one-year follow-up was available for 452 patients.

The top three inhaled therapies used in this real-world cohort include: a LAMA (long-acting muscarinic antagonist) alone (prescribed to 39.1%); or LAMA in combination with LABA (long-acting beta2-agonist) plus inhaled corticosteroids (ICS, prescribed to 39%); or LABA/ICS alone (14.4%).

The bronchodilator theophylline was used in 11.4% of patients. (Bronchodilators are therapies that dilate and relax the bronchi tissue to ease the flow of air in the lungs.)

In agreement with the 2017 GOLD guidelines, four groups were established according to the type of therapy used:

• group A: treatment with either a short-acting or a long-acting bronchodilator;
• group B: single use of LAMA or LABA, or the combination of LAMA plus LABA;
• group C: LAMA, or LABA plus ICS, or LAMA plus LABA;
• group D: LAMA, or LABA plus ICS, or LAMA plus LABA, or the triple combination LAMA/LABA/ICS.

The analysis revealed that 42.7% of patients in group A, 61.6% of group B, and 30% of group C were following inappropriate therapy, mainly overuse of ICS. In contrast, 6.9% of patients in group D were following an inappropriate therapy.

The overall discrepancy rate between GOLD recommendations and clinical practice was 40.5% when considering all groups.

Among non-pharmacological therapies, oxygen therapy at home was used by 3.9% of patients, followed by 1.8% using noninvasive positive pressure ventilation at home. Vaccination was used by 0.3%, pulmonary rehabilitation by 0.1% and lung transplant by 0.08%. Among these patients, more than a third (33.2%) had poor adherence to treatment after six months of follow-up.

The majority of them (30%) stopped treatment because they were feeling better; 18.5% considered the treatment ineffective, while 14.5% had trouble accessing the therapies. A minority (1.9%) said they were worried about the adverse side effects, and 0.7% considered the economic burden. The rest gave other reasons.

Among patients with one-year follow-up data, results showed that treatment resulted in little improvement in lung function and lessening of symptoms, as shown by a decrease in the ratio of forced expiratory volume in one second (FEV1) over forced volume vital capacity (FVC) and a higher mMRC score. (A higher score indicates impaired health-related quality of life and a high symptom burden.)

No changes were seen in the COPD Assessment Test (CAT) score, which assesses the impact of COPD symptoms on patients’ overall health.

Overall, these findings highlight “a significant discrepancy between recommendations for managing patients with COPD in GOLD report, and in real-world clinical practice in China,” researchers wrote.

Specifically, researchers reported an over-prescription of ICS and a less-frequent use of non-pharmacologic therapy. Patient adherence to treatment was poor and the effectiveness of therapies unsatisfactory.

“More attention should be paid to the implementation of recommendations and standardized administration of therapies,” the team concluded.