Inhaled corticosteroids increasingly used for COPD outside recommended indications

Key takeaways:

• Nearly 45% of veterans with COPD received inhaled corticosteroids as their first therapy without meeting a guideline-recommended indication.
• This appeared more common among veterans living in rural areas.

From 2010 to 2018, a rising number of veterans with COPD received inhaled corticosteroid prescriptions as first-line therapy outside recommended indications, according to results published in Annals of the American Thoracic Society.

“Our study has the greatest implications for health systems that are trying to improve value-based prescribing,” Kevin I. Duan, MD, MS, acting instructor in the division of pulmonary, critical care and sleep medicine at University of Washington, told Healio. “However, for the everyday clinician, the study is a reminder that updating our inhaler prescribing norms to better align with the latest evidence and recommendations is needed. Currently, our study suggests that just under half of patients with COPD starting inhalers are getting a therapy that is not the recommended first-line therapy.”

In a cross-sectional study, Duan and colleagues analyzed 131,009 veterans with COPD and new use of inhaler therapy in the U.S. Department of Veterans Affairs between January 2010 and December 2018, to determine national trends in low-value inhaled corticosteroid prescriptions during this timeframe using multivariable logistic regression models.

Researchers defined an inhaled corticosteroid prescription as “low value” if it was given to a patient without asthma, with a low risk for future exacerbations or with a serum eosinophil count of less than 300 cells/L.

Of the total cohort, nearly 45% (n = 57,472) of veterans had low-value inhaled corticosteroids as their first therapy, and this prescription appeared frequently across states (range, 32%-56%).

Researchers found that the chances for a low-value inhaled corticosteroid prescription grew as the years progressed, which can be seen through a 0.42 percentage-point rise (95% CI, 0.31-0.53) per year in the probability for this outcome following adjustment for several covariates.

Researchers also divided the cohort according to rural (n = 54,151; mean age, 68 years; 2% women; 88% white) vs. urban (n = 76,297; mean age, 68 years; 3% women; 77% white) residence and conducted fixed effects logistic regression to see if low-value inhaled corticosteroid prescribing differed by location.

Results showed the probability for low-value inhaled corticosteroids heightened by 2.5 percentage points (95% CI, 1.9-3.1) for veterans living in rural vs. urban areas after adjustment.

Using the complexity level of the VA medical center where each patient was treated, researchers observed increased probabilities for low-value inhaled corticosteroid prescriptions among rural residents treated in the most complex (2.5 percentage points; 95% CI, 1.8-3.2) and moderately complex (1.6 percentage points; 95% CI, 0.01-3.2) facilities vs. urban residents.

Compared with urban residents treated in a least complex facility, rural residents in the same facilities did not have a higher probability for the assessed prescription, according to researchers.

“For patients with COPD, the differences in disease burden and clinical outcomes between rural and urban areas is well documented, which was part of the motivation to conduct our rural-urban analysis,” Duan told Healio. “While we did detect a small difference, I was surprised that there wasn’t a more pronounced difference. The more important finding is that the issue of low-value prescribing is widespread and persistent over time, in both rural and urban areas alike.”

Further, researchers observed similar results during sensitivity analyses that used the GOLD 2017 recommendations for classifying low-value inhaled corticosteroids, which do not factor in serum eosinophil counts.

A sensitivity analysis that used the 6-point National Center for Health Statistics Urban-Rural Classification scheme also showed that more rurality meant higher chances for receiving low-value inhaled corticosteroids, according to researchers.

After accounting for spirometric confounders, an analysis of 12,531 veterans with spirometry results revealed a 2.2% (95% CI, 0.1%-4.3%) heightened probability for receiving low-value inhaled corticosteroids among those living in rural vs. urban areas.

“Additional work is needed to evaluate whether similar prescribing patterns are occurring outside of the VA system,” Duan told Healio.