The burden of chronic obstructive pulmonary disease associated with maintenance monotherapy in the UK

Abstract

Background: This study characterized a cohort of chronic obstructive pulmonary disease (COPD) patients on maintenance bronchodilator monotherapy for ≥6 months to establish their disease burden, measured by health care utilization.

Methods: Data were extracted from the UK Clinical Practice Research Datalink and linked to Hospital Episode Statistics. The monotherapy period spanned the first prescription of a long-acting β₂-adrenergic agonist or a long-acting muscarinic antagonist until the end of the study (December 31, 2013) or until step up to dual/triple therapy, for example, addition of another long-acting bronchodilator, an inhaled corticosteroid, or both. A minimum of four consecutive prescriptions and 6 months on continuous monotherapy were required. Patients <50 years old at first COPD diagnosis or with another significant respiratory disease before starting monotherapy were excluded. Disease burden was evaluated by measuring patients' rate of face-to-face interactions with a health care professional (HCP), COPD-related exacerbations, hospitalizations, and referrals.

Results: A cohort of 8,811 COPD patients (95% Global initiative for chronic Obstructive Lung Disease stage A/B) on maintenance monotherapy was identified between 2002 and 2013; 45% of these patients were still on monotherapy by the end of the study. Median time from first COPD diagnosis to first monotherapy prescription was 56 days, while the median time on maintenance bronchodilator monotherapy was 2 years. The median number of prescriptions was 14. On average, patients had 15 HCP interactions per year, and one in ten patients experienced a COPD exacerbation (N=8,811). One in 50 patients were hospitalized for COPD per year (n=4,848).

Conclusion: The average monotherapy-treated patient had a higher than average HCP interaction rate. We also identified a large cohort of patients who were stepped up to triple therapy despite a low rate of exacerbations. The use of the new class of long-acting muscarinic antagonist/long-acting β₂-adrenergic agonist fixed-dose combinations may provide a useful step-up treatment option in such monotherapy patients, before the use of inhaled corticosteroids.

Keywords: COPD; UK primary care setting; bronchodilators; monotherapy; prescribing patterns.

Figure 1

Flowchart for sample selection. Abbreviations: COPD, chronic obstructive pulmonary disease; CPRD, Clinical Practice Research Database; LABA, long-acting β₂-adrenergic agonist; LAMA, long-acting muscarinic antagonist; px, prescription.

Figure 2

Medication switches in patients initially prescribed LAMA or LABA monotherapy. Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β₂-adrenergic agonist; LAMA, long-acting muscarinic antagonist.

Figure 3

Time on monotherapy by the type of therapy received at the end of the study. Note: Thirteen patients were stepped up to a LABA + LAMA fixed-dose combination. Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β₂-adrenergic agonist; LAMA, long-acting muscarinic antagonist.

Figure 4

Frequency and rate of short-acting bronchodilator usage by monotherapy duration. Note: Frequency (A) and rate (B) of short-acting bronchodilator usage by monotherapy duration.