Inhaled corticosteroids in COPD with mild or moderate airflow limitation: who is suitable for a trial of withdrawal?

Conference:

SAPC ASM 2019 - Exeter

Talk Code:

P2.37

Presenter:

Patrick White

Co-authors:

GilGill Gilworth, M Thomas, Chris Corrigan, Patrick Murphy, Nicholas Hart, Les Hamilton, Timothy Harries.

Author institutions:

1King's College London, London, UK, University of Southhampton, Southampton UK, Lane Fox Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK.

Problem

Inappropriate use of high-dose inhaled corticosteroids (HD-ICS) increases pneumonia risk and other complications in patients with COPD. Most inappropriate prescribing of HD-ICS takes place in primary care. The main indication for prescription of HD-ICS is a history of exacerbations in COPD patients with symptomatic disease. Patients who are inappropriately prescribed HD-ICS should undergo a trial of withdrawal. In this study we aimed to assess the feasibility of identifying in primary care, COPD patients with mild or moderate airflow limitation suitable for withdrawal of HD-ICS.

Approach

A search of UK primary care electronic records was carried out to identify COPD patients (asthma excluded) recently prescribed HD-ICS with no evidence of severe airflow limitation in the past year. Before assessment with a view to HD-ICS withdrawal, each record was scrutinized for evidence of asthma, or a history of one severe exacerbation (exacerbation leading to hospital admission) or two or more moderate exacerbations (exacerbation requiring oral antibiotics or oral steroids). Patients were excluded if any of these indications for HD-ICS were present. Eligible patients were invited to COPD review by their GP.

Findings

392 eligible patient records were identified by electronic search from a COPD patient population of 2967. Frequent inconsistencies in diagnosis and recording of exacerbations were seen in patient notes, often with inability to assign prescription of antibiotics and prednisolone (rescue pack) to exacerbation occurrence. 243 patients were excluded from HD-ICS withdrawal as treatment was indicated. Main exclusion factors were: ≥2 moderate or ≥1 severe exacerbations (35%), severe airflow obstruction (27%), airflow reversibility (6%), active lung cancer (4%), and dementia (3%). 149 patients were invited for COPD review. 61 attended, 27 declined in writing, 61 were not contactable or refused on the telephone. 21 patients were excluded due to: FEV1 reversibility (49%), severe airflow limitation (29%), no airflow obstruction (10%), frequent exacerbations in past year (4%), hospital admission for exacerbation (4%), BMI >35 (4%). 40 (10%) patients were suitable and available for trial of HD-ICS withdrawal.

Consequences

The identification in primary care electronic patient records of COPD patients with mild or moderate airflow limitation, suitable for a trial of withdrawal of HD-ICS prescription, is a considerable challenge. To identify suitable patients general practices should make hand searches for exacerbation history and should be competent in reliable spirometry to diagnose reversibility.

Submitted by:

Patrick T White

Funding acknowledgement:

This paper presents independent research funded by the NIHR under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0214-33060). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.