From Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to current clinical practice : an overview of the pharmacological therapy of stable chronic obstructive pulmonary disorder.
BACKGROUND
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been promulgated to improve the management of chronic obstructive pulmonary disorder (COPD).


OBJECTIVE
To evaluate the extent to which the current therapeutic approach to COPD conforms to GOLD guidelines.


METHODS
This was a multicentre observational study of elderly COPD patients enrolled for acute care in general medicine or geriatric wards in tertiary hospitals in Italy in April 2002. Our series consisted of 471 patients >64 years of age consecutively admitted for acute exacerbations of COPD to wards participating in the study. Data describing drugs used prior to exacerbation and prescribed at discharge were collected using a standardised protocol. Changes in prescription at discharge were then compared with home therapy. Demographic variables and indices of COPD severity and co-morbidity were tested as potential correlates for the main outcome measure 'variant prescription', i.e. prescription of a drug considered as a third-line treatment (e.g. methylxanthines) or not recommended (e.g. mucolytics) by GOLD guidelines. The correlation was assessed first by univariate analysis and then by logistic regression analysis.


RESULTS
At discharge, prescription of short-acting beta(2)-adrenoceptor agonists had decreased from 26.3% to 14.0%. Conversely, increases in prescription of long-actingbeta(2)-adrenoceptor agonists (from 43.1% to 68.4%), inhaled corticosteroids (50.7% to 69.6%) and anticholinergics (17.2% to 22.3%) were seen. The rate of use of methylxanthines was 49.7% before admission and 44.8% at discharge, with previous use being the main correlate of discharge prescription for this class of drugs (odds ratio [OR] = 4.35; 95% CI 2.88, 6.54). The rate of use of mucolytics was 26.3% before admission and 26.8% at discharge, with use of mucolytics prior to admission being the only correlate of discharge prescription (OR = 4.10; 95% CI 2.47, 6.82).


CONCLUSIONS
Hospitalisation resulted in increased adherence to GOLD guidelines in patients with COPD, but the rate of use of anticholinergics was distinctly low and that of methylxanthines and mucolytics surprisingly high. A carry-over effect (i.e. of therapy prescribed by general practitioners on that prescribed by hospital-based physicians) likely accounts for most of the 'variant prescriptions' seen at discharge from the acute care hospital.
Incalzi
Raffaele Antonelli
RA
Chair of Geriatric Medicine, University Campus Bio-Medico, Rome, Italy.
Corsonello
Andrea
A
Pedone
Claudio
C
Masotti
Giulio
G
Bellia
Vincenzo
V
Grassi
Vittorio
V
Rengo
Franco
F
D000368:Aged; D000375:Aging; D004345:Drug Industry / Q000639:trends; D004363:Drug Utilization; D005260:Female; D019983:Guideline Adherence; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D015337:Multicenter Studies as Topic; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis* / Q000188:drug therapy*