Real-world COPD treatment practices in SG lag behind updated guidelines

Many patients with chronic obstructive pulmonary disease (COPD) in Singapore could benefit from treatment escalation under the latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, as reported by a group of researchers.

“Since 2019, GOLD has suggested using blood eosinophil count to guide treatment adjustments in COPD patients at high exacerbation risk. Previously, treatment escalation was commonly managed without relying on blood eosinophil count,” researchers from Changi General Hospital, Singapore, Singapore, noted. [https://goldcopd.org/wp-content/uploads/2019/11/GOLD-2020-REPORT-ver1.1wms.pdf; Eur Respir J 2019;53:1900164]

In a retrospective analysis of a subset of Changi General Hospital COPD data dating from October 2017 to October 2020, around 84 percent of patients admitted for exacerbations would have been eligible for treatment escalation per GOLD 2019 or 2023 recommendations. Of these patients, only 13.7 percent and 15.0 percent had their treatment adjusted in line with the GOLD 2019 and 2023 guidelines, respectively. [J Thorac Dis 2024;16:847-861]

Upon discharge, 76.5 percent of patients remained on the same treatment regimen they were receiving upon admission.

The findings, according to the researchers, align with the concept of therapeutic inertia in COPD management and underscore a gap between what current guidelines recommend and what occurs in everyday clinical practice.

Reality check

“Despite general acceptance of clinical practice recommendations among clinicians, discordance with real-world practice has been similarly observed across different countries and diverse healthcare settings,” they pointed out.

In Spain, a study showed that the treatment prescribed for more than 50 percent of COPD patients fell outside the scope of the GOLD recommendations. The same was true in the UK where evidence indicated that prescribing practices amongst primary care providers mostly diverged from the GOLD and National Institute for Health and Care Excellence recommendations. Likewise, in the US, a study showed that 67 percent of patients received treatments that did not conform to the GOLD strategy. [Int J Chron Obstruct Pulmon Dis 2021;16:3131-3143; Int J Chron Obstruct Pulmon Dis 2014;9:889-904; Int J Chron Obstruct Pulmon Dis 2012;7:201-209]

“There are several possible reasons that may account for nonescalation of therapy. Firstly, patients may be averse to changing their current treatment regimen, as a change in medication can often lead to increased costs and/or confusion,” the researchers said.

Treatment escalation may also involve adding new medications, which can make treatment regimens more complex and, in turn, adversely affect adherence. But single-device combination therapies have been developed specifically to address this problem, according to the researchers.

Meanwhile, clinicians may be reluctant to introduce inhaled corticosteroids (ICS) due to concerns about pneumonia, they added. Some prioritize managing the acute exacerbation and postpone decisions about long-term therapy until a follow-up appointment when the patient is more stable. Others even prefer to delegate the decision-making to the primary care physician who has a more established relationship with the patient and a deeper understanding of their overall health, as the researchers pointed out.

“Nevertheless, encouraging guideline-concordant treatment escalations during an exacerbation represents a window of opportunity to optimize the long-term management of patients with COPD. Examples of this include both nonpharmacological (disease-specific education, smoking cessation, psychosocial support) and pharmacological measures (escalation of inhaler therapy), which can help to reduce the risk of recurrent exacerbations,” they said.

Closing the gap

The present study included 268 COPD patients aged ≥40 years (mean 73 years, 91.0 percent men, 56.7 percent Chinese) who were hospitalized for an exacerbation. At admission, 19 percent of patients were receiving long-acting muscarinic antagonist (LAMA), 59 percent were receiving LAMA plus a long-acting beta2-agonist (LABA), and 22 percent were receiving ICS plus LABA.

In additional analysis, GOLD-concordant treatment escalations were predicted by a lower measured postbronchodilator FEV₁ (p=0.028) and an increased number of hospital admissions or emergency department visits in the past year (GOLD 2019: p=0.048; GOLD 2023: p=0.049).

Despite the limited generalizability of the findings due to a small sample size, the findings point to a need for systematic, coordinated interventions to aid with the alignment of real-world practice with updated guidelines and treatment recommendations, according to the researchers. This strategy, they added, may ultimately prompt a more individualized treatment based on specific treatable traits.

“Subsequent studies comparing the real-world treatment patterns with the latest available treatments using the GOLD 2023 recommendations are needed to evaluate the true prevalence, challenges in implementation and extent of therapeutic inertia, and assess potential barriers to treatment escalation as recommended,” the researchers said.