SG: COPD severity a key factor when choosing between therapies

Chronic obstructive pulmonary disease (COPD) patients initiating treatment with a long-acting muscarinic antagonist (LAMA) plus a long-acting β2-agonist (LABA) tend to have higher disease severity than those who are started on LAMA, according to real-world data from Singapore. However, there are as many patients who experience clinical worsening in the LAMA group as there are in the LAMA+LABA group.

“At baseline, patients prescribed LAMA+LABA had on average … lower body mass index (BMI), higher COPD Assessment Test (CAT) score, and worse lung function in the main analysis, whether patients who died during the study period were included or excluded,” the investigators pointed out.

“Of those patients who initiated treatment with LAMA+LABA, only 5–10 percent of patients were stepped up from LAMA monotherapy, suggesting that dual therapy is being prescribed as initial maintenance treatment in more severe patients,” they added.

Over 12 months of follow-up, close to half of the population had clinical worsening. The rates were similar in the LAMA (52 percent) and LAMA+LABA (46 percent) groups, although median time-to-clinical worsening was longer in the former (340 vs 154 days). [Int J Chron Obstruct Pulmon Dis 2022;17:1349-1363]

“Exacerbations were more common in the LAMA+LABA cohort, likely because these patients had more exacerbations at baseline, which are a predictor of future exacerbations. However, patients who initiated treatment with LAMA+LABA were less likely to change treatment compared with those who initiated treatment with LAMA, despite the higher average severity of the LAMA+LABA cohort at baseline,” according to the investigators. [Eur Respir J 2013;42:636-646]

In the local context, there are several factors to consider before treatment can be escalated to include an inhaled corticosteroid (ICS) component in patients receiving dual therapy, the investigators noted.

Physician’s reluctance to escalate from dual to triple therapy can be attributed to uncertainty around ICS prescribing and dose selection, increased medication costs, lack of regular blood eosinophil count monitoring as recommended to support treatment escalation, or the challenges involved in identifying specific patients who would benefit from the addition of ICS to their treatment, they added. [tinyurl.com/2yf8xorj; tinyurl.com/y7uco56c; Chest 2020;157:846-855; Eur Respir J 2018;52:1801219]

“Moreover, the addition of a standalone ICS component may require use of multiple inhalers with different inhalation techniques, and as such may require patient education on correct use of the new device for successful treatment,” the investigators said. [Int J Chron Obstruct Pulmon Dis 2016;11:2509-2517]

In total, 261 COPD patients (mean age 72 years, 91.6 percent male, 60.9 percent Chinese) from Changi General Hospital were included in the study (LAMA: n=73; LAMA+LABA: n=188). The prevalence of comorbidities was similar between treatment groups.

The findings indicate that early disease identification and treatment optimization are necessary to improve outcomes for patients with COPD, the investigators said. “The data warehouse compiled for this study represents a valuable source of real-world data in patients with COPD in Singapore subject to further validation.”