Inappropriate overuse of inhaled corticosteroids in patients with moderate COPD in UK primary care

Introduction: UK and international guidelines recommend that patients with moderate COPD (FEV1 50-79% predicted) uncontrolled by a short-acting bronchodilator alone should receive maintenance monotherapy with a long acting beta agonist (LABA) or long acting muscarinic antagonist (LAMA). Add-on inhaled corticosteroids (ICS) are only recommended in those with FEV1 <50% &/or exacerbations. We present data quantifying the prescribing of ICS in routine primary care. Methods: A retrospective observational study of management of moderate COPD in 314 patients (FEV1 50-79% predicted. FEV1/FVC<70%) diagnosed during/before 2007. Three years' patient data were collected from routine medical records in 10 general practices in England. Analysis included stratification by severity of disease, presence of concomitant asthma & frequency of exacerbation - factors which may affect ICS use. Results: 234 (75% of those with moderate COPD) received ICS, by “stand-alone” ICS inhaler (n=69, 22%) &/or as a combination ICS-LABA device (n=188, 60%). 151 of 205 (74%) without concomitant asthma received ICS, vs 83/109 (76%) of those with asthma. The annualised median number of recorded exacerbations/year was 0.67 (range 0-6.67) overall and for those without concomitant asthma. 70% of those without asthma who did not have recorded exacerbations were prescribed ICS. Conclusion: ICS are prescribed for most patients with moderate COPD, although not recommended in guidelines or product licences. This prescribing cannot be explained by concomitant asthma or frequent exacerbations. Inappropriate use of ICS increases costs & puts patients at risk of side effects. GPs should audit their use of ICS in moderate COPD.