1. Differences in the recommended initial therapy of COPD according to GOLD 2006 and 2011 revisions Ivan Vyshnyvetskyy1, Yuriy Mostovoy2, Olexiy Onyshchenko1 1 – Department of Internal Medicine and General Practice - Family Medicine, Donetsk National Medical University, Donetsk, Ukraine, 2 – Department of Propedeutic Therapy, National Pirogov Memorial Medical University,Vinnitsa, Ukraine
GOLD 2011 (
Izquierdo JL, Martín A, de Lucas P, et al. Int J Chron Obstruct Pulmon Dis. 2010;5:241-9
Corrado A, Rossi A. How far is real life from COPD therapy guidelines? An Italian observational study. Respir Med Jul;106(7):
Asche CV, Leader S, Plauschinat C, Adherence to current guidelines for chronic obstructive pulmonary disease (COPD) among patients treated with combination of long-acting bronchodilators or inhaled corticosteroids. Int J Chron Obstruct Pulmon Dis. 2012;7: Epub 2012 Mar 15.
AEM Lucas, FWJM Smeenk, IJ Smeele, and CP van Schayck Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study Family Practice (2008) 25(2): 86-91
de Miguel-Díez J, Carrasco-Garrido P, Rejas-Gutierrez J et al. Inappropriate overuse of inhaled corticosteroids for COPD patients: impact on health costs and health status. Lung Jun;189(3):
Booth H, Georgopoulou S, Pinnock H, et al. High rates of over-treatment of COPD in primary care: what risks to patients and costs to health services?. Eur Respir J 2011; 38 Suppl. 55:181s.
Introduction
Results
New revision of the GOLD strategic document has widened the possibilities to prescribe ICS/LABA in high-risk COPD patients1. But the magnitude of possible shifts in ICS usage remains unclear.
It is also well recognized that physicians commonly do not follow guidelines and prescribe ICS and ICS/LABA in COPD almost as frequently as in asthma2,3,4. It results in increase of side effects and significant financial waste5,6. Contrary to recommendations of previous GOLD revisions (2006 and annual updates) up to 50% of COPD patients could be considered “over-treated”, generally by ICS/LABA combinations3,7.
We hypothesized that application of GOLD 2011 recommendations would intensify starting treatment in significant proportion of COPD patients and would bring it nearer to established real-life patterns of care.
According to GOLD 2006 criteria 71 (55%) and 58 (45%) patients were stages I-II and III-IV, respectively. Five (3,9%) patients should be prescribed with SABA±SAMA only, 97 (75,2%) with LABA or LAMA monotherapy and 27 (20,9%) required ICS/LABA therapy.
According to GOLD (13,2%), 42 (32,6%), 6 (4,6%) and 64 (49,6%) patients were Group A, B, C and D, respectively. Thus, as initial therapy, only 45 (34,9%) should be prescribed monotherapy with long-acting bronchodilators (BD) but 67 (51,9%) patients required therapy with ICS/LABA (fig. 1).
In cohort of treated COPD patients real-life patterns of inhaled therapy prescriptions better corresponded to GOLD 2011 rather than to GOLD 2006 recommendations (fig. 3).
Fig. 3 – Correspondence of real-life prescriptions to different GOLD revisions
Fig. 1 – Recommended initial therapy in the same stable COPD patients according to GOLD 2006 and 2011 (n=129)
Aims
To demonstrate the magnitude of difference in recommended first-line treatment of stable COPD according to GOLD 2006 or 2011 revisions
To evaluate how this difference corresponds to real-life practice patterns in primary care physicians
Treatments prescribed by primary care physicians were almost 1,5 times more likely to comply with guidelines if we use GOLD 2011 comparing to GOLD The proportion of patients being over-treated with ICS according to GOLD 2006 decreased greatly (41,6% to 14,3%) after considering GOLD 2011.
Methods
In accordance with GOLD 2011 treatment scheme, initial therapy was required to be changed in 52 (40,3%) patients. In 12 of 129 (9,3%) cases we had to administer less intensive therapy (with short-acting BD only instead of long-acting BD), and 40 (31,0%) patients required more intensive treatment, usually LABA/ICS instead of monotherapy with LABA or LAMA (fig. 2).
Conclusion
Extracted data from regional “Program on improving of COPD diagnostics quality”
129 patients with definite COPD:
52 treatment-naïve patients
77 patients on inhaled treatment, prescribed by primary care physicians < 1 month ago
Spirometry, history of exacerbations and CAT score were analyzed to allocate patients to groups of guideline-concordant treatments
Among patients on treatment, only those were analyzed who had been able to recall their functional status parameters at the time before starting treatment and had completed “anamnestic” pre-treatment CAT
Patient charts were reviewed by 3 independent qualified academic specialists
In patients allocated to Groups C and D (GOLD 2011) the choice between ICS/LABA or LAMA was made with a predominance of ICS/LABA to reflect the reality of the national market
Final allocation to a specific treatment was based on consensus judgment
Comparisons of first-line treatment distinctions according to GOLD 2006 and 2011 and correspondence with real-life prescriptions were performed
In comparison with previous GOLD revision, new treatment scheme leads to another first-line treatment choice in 40% of stable COPD patients (in 9% with reduced and in 31% with increased intensity of treatment). In light of widening of indications for ICS use, guideline-discordant “ICS over-treatment” is expected to be more rare in real-life setting. This to some extent reflects the established patterns of care by primary care physicians and makes real-life practice closer to recommended standards.
Fig. 2 – Shifts of first-line treatment required by GOLD 2011
Bibliography
GOLD 2011 (
Izquierdo JL, et al. Int J Chron Obstruct Pulmon Dis. 2010;5:241-9
Corrado A, Rossi A. Respir Med Jul;106(7):
Asche CV, et al. Int J Chron Obstruct Pulmon Dis. 2012;7:201-9.
AEM Lucas, et al. Family Practice (2008) 25(2): 86-91
de Miguel-Díez J, et al. Lung Jun;189(3):
Booth H, et al. Eur Respir J 2011; 38 Suppl. 55:181s.
To ascertain that use of “anamnestic” pre-treatment CAT assessment in a subgroup of patients did not bias the data we separately analyzed 52 treatment-naïve patients and obtained results very close to the whole cohort of patients.