Triple inhaled therapy in COPD patients: determinants of prescription in primary care

Objective: To assess the incidence and determinants of the triple inhaled therapy in chronic obstructive pulmonary disease (COPD) primary care patients. Methods: Data derived from the Health Search Database (HSD) gathering information on 700 Italian general practitioners. A cohort of COPD patients, prescribed for the first time with inhaled treatments, was followed-up between January 2002 and December 2014. The outcome was the first incident prescription of a triple inhaled therapy, namely the combination of inhaled corticosteroids (ICS), long-acting beta agonists (LABA), and long-acting muscarinic antagonists (LAMA). Cox regressions were used to test the association (hazard ratios, HR) between candidate determinants and the outcome. Results: Out of 17589 patients (mean age 71.1 +/- 11.3 years; 37.4% females), 3693 (21%) were prescribed with a triple inhaled therapy during follow-up. Older age (HR=1.79 to 2.61), current and former smoking habit (HR=1.72 and 1.66), higher GOLD stage (HR=1.45 to 2.79), the number of moderate and severe COPD exacerbations (HR=1.10 to 2.63), and heart failure (HR=1.17) resulted statistically significantly associated with an increased incident prescription of the triple inhaled therapy. Female sex (HR=0.80) and some co-morbidities (HR=0.21 to 0.87) resulted negatively associated with the outcome. Furthermore, patients initially treated with LAMA (HR=1.5) and LABA/ICS (HR=1.23) were more likely to escalate to the triple therapy, than those on LABA. Conversely, patients initially treated with ICS presented a negative hazard (HR=0.72). Conclusions: The knowledge of demographic and clinical determinants of the escalation to the triple inhaled therapy in real-world COPD patients may help clinicians to better personalize respiratory pharmacological treatments of their patients, and inform international societies that issue clinical guidelines.