Managing chronic obstructive pulmonary disease in primary care: clinical characteristics of patients receiving inhaled corticosteroids

Background Inhaled corticosteroid (ICS) therapy in patients with chronic obstructive pulmonary disease (COPD) has been associated with a variety of unfavourable effects, including increased risk of pneumonia, and is only recommended if specific characteristics are present to ensure patients derive the most benefit. Aim The primary objective was to evaluate the clinical characteristics of patients prescribed ICS therapy for COPD management in two primary care clinics at an academic medical centre. The secondary objectives were to examine provider assessment and barriers to prescribing patterns concordant with guidelines in the ambulatory care setting. Methods A retrospective 24-month study at two primary care clinics was undertaken at an academic medical centre in Arkansas, United States and focused on adult patients who were prescribed ICS maintenance therapy. Individuals within each clinic were identified by Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes indicative of COPD from 1 January 2019 to 31 December 2020. Spirometry was also required to confirm diagnosis. Results Of the 189 unique patients identified, 100 were eligible for review of clinical characteristics. All patients received ICS therapy in combination with a long-acting beta agonist (LABA) with 55% of patients also receiving a long-acting muscarinic antagonist (LAMA). Furthermore, 32% of patients visited the emergency department or were hospitalised for a COPD exacerbation within the previous year. Approximately 47% and 36% of patients had a history of pneumonia and an eosinophil count <100 cells/mcL respectively. Barriers to guideline adherence were identified through open discussion with providers within each clinic, which included a lack of readily available resources in the clinic setting, suboptimal recognition of clinical tools within the electronic medical record and alternative guideline preferences. Conclusion A small portion of patients evaluated in the study were discovered to have clinical characteristics suggestive of strong ICS benefit as these therapies either lacked efficacy due to low blood eosinophil count or exacerbation rate (80% and 68% respectively), or increased the risk for harm in this population secondary to previous pneumonia diagnosis (47%).