Prompt Initiation of Triple Therapy in Patients with Chronic Obstructive Pulmonary Disease Reduces Exacerbations
Presenter: Charlie Strange, MD, Medical University of South Carolina, Charleston, SC
A summary of the session, Prompt initiation of maintenance therapy in the United States (PRIMUS): an analysis of triple therapy following a disease exacerbation among patients with COPD, October 17, 2021, Chest 2021.
The prompt initiation of triple therapy in patients with chronic obstructive pulmonary disease (COPD) who have had disease exacerbations can prevent further exacerbations, according to this retrospective study of healthcare claims. Results showed that patients who received triple therapy—inhaled corticosteroid (ICS), a long-acting β2-agonist (LABA), and a long-acting muscarinic antagonist (LAMA)—within 30 days had fewer disease exacerbations than those who received delayed therapy.
“Treatment guidelines recommend escalation from dual to triple therapy with ICS/LABA/LAMA for COPD patients after 2 or more moderate exacerbations or a single severe disease exacerbation that requires hospitalization,” said Charlie Strange, a study investigator. “One question we asked was whether the time from initiation of triple therapy following those exacerbations made a difference in subsequent exacerbations, as well as the costs in the following year.”
Investigators searched the IBM MarketScan database of commercial and Medicare supplement and multistate Medicaid recipients for patients treated for COPD exacerbations between January 1, 2011, and March 31, 2019. They found 24,770 patients, mean age 62 years, who had COPD exacerbations and had triple therapy initiated. “We used this metric to find the time at which either second moderate or first severe exacerbation occurred and then counted the months until the patient received triple therapy either as combined inhalers or a single all-in-one inhaler,” he said.
Of the patients included, 31% had prompt triple therapy, defined as less than 30 days form the index date to initiation of triple therapy. 39% had delayed triple therapy (31–180 days), and 30% had very delayed triple therapy (181–365 days). Mean time to triple therapy initiation was 119.7 days.
“We found that post-index exacerbation frequency increased as time to triple therapy increased,” Strange said. “Each 30-day delay of triple therapy was associated with 10% to 12% increased odds of any exacerbation; 7% increased odds of a severe exacerbation; 4.3% increase in number of exacerbations; and 1.8% and 2.1% increases in all-cause and COPD-related costs.”
“Results show every month of delay after that index exacerbation added cost and increased the treatment of further exacerbations over the following year,” Strange said. “The amount of money spent on exacerbations was between $30,000 and $40,000. By using a multivariate logistic, binomial, linear regression, we were able to march out the risk factors for each of the qualities of patients to achieve these outcomes of further exacerbations. The relative odds ratio of exacerbations associated with each 30-day delay in triple therapy ended up being more than 1.1. That translates to an increasing number of exacerbations over time the longer that triple therapy was delayed, and as a result of that more money was spent. Triple therapy costs a little more than double therapy, but the amount of money that this delay ensues is easily compensated for by the extra costs of therapy over that subsequent year.”
In conclusion, Strange said, “Delaying triple therapy after 1 severe or 2 moderate COPD exacerbations markedly increases the risk of a subsequent exacerbation and increases overall healthcare costs. Evaluating treatment protocols may be warranted to ensure prompt initiation of triple therapy and optimal health outcomes in patients with COPD. If a patient lands in the hospital who has a severe single exacerbation, we should get that patient started on triple therapy.”
Disclosures
Charlie Strange, MD: AstraZeneca (Consultant)
References
Global Initiative for Chronic Obstructive Lung Disease. 2021 Global Strategy for the Prevention, Diagnosis, and Management of COPD. https://goldcopd.org/2021-gold-reports/. Accessed October 25, 2021.
Tkacz J, Evans K, Touchette DR, et al. Prompt initiation of maintenance therapy in the United States (PRIMUS): an analysis of triple therapy following a disease exacerbation among patients with COPD. Chest 2021; 160(4)(Suppl): A1809-A1810. doi: 10.1016/j.chest.2021.07.1635