title: The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK.
abstract: BACKGROUND
  Real-world prescription pathways leading to triple therapy (TT) (inhaled corticosteroid [ICS] plus long-acting β2-agonist bronchodilator [LABA] plus long-acting muscarinic antagonist) differ from Global initiative for chronic Obstructive Lung Disease [GOLD] and National Institute for Health and Care Excellence treatment recommendations. This study sets out to identify COPD patients without asthma receiving TT, and determine the pathways taken from diagnosis to the first prescription of TT.
  
  
  METHODS
  This was a historical analysis of COPD patients without asthma from the Optimum Patient Care Research Database (387 primary-care practices across the UK) from 2002 to 2010. Patient disease severity was classified using GOLD 2013 criteria. Data were analyzed to determine prescribing of TT before, at, and after COPD diagnosis; the average time taken to receive TT; and the impact of lung function grade, modified Medical Research Council dyspnea score, and exacerbation history on the pathway to TT.
  
  
  RESULTS
  During the study period, 32% of patients received TT. Of these, 19%, 28%, 37%, and 46% of patients classified as GOLD A, B, C, and D, respectively, progressed to TT after diagnosis (P<0.001). Of all patients prescribed TT, 25% were prescribed TT within 1 year of diagnosis, irrespective of GOLD classification (P=0.065). The most common prescription pathway to TT was LABA plus ICS. It was observed that exacerbation history did influence the pathway of LABA plus ICS to TT.
  
  
  CONCLUSIONS
  Real life UK prescription data demonstrates the inappropriate prescribing of TT and confirms that starting patients on ICS plus LABA results in the inevitable drift to overuse of TT. This study highlights the need for dissemination and implementation of COPD guidelines to physicians, ensuring that patients receive the recommended therapy.
authors.affiliation: Department of Respiratory Medicine, University Hospital Ghent, Ghent, Belgium ; Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands ; Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, Netherlands.
authors.forename: Guy
authors.initials: G
authors.lastname: Brusselle
authors.affiliation: Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK ; Research in Real Life (RiRL), Singapore.
authors.forename: David
authors.initials: D
authors.lastname: Price
authors.affiliation: Box Surgery, Wiltshire, UK.
authors.forename: Kevin
authors.initials: K
authors.lastname: Gruffydd-Jones
authors.affiliation: Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
authors.forename: Marc
authors.initials: M
authors.lastname: Miravitlles
authors.affiliation: Novartis Pharma AG, Basel, Switzerland.
authors.forename: Dorothy L
authors.initials: DL
authors.lastname: Keininger
authors.affiliation: Research in Real Life (RiRL), Singapore.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Stewart
authors.affiliation: Novartis Pharmaceuticals Limited, Horsham, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Baldwin
authors.affiliation: Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
authors.forename: Rupert C
authors.initials: RC
authors.lastname: Jones
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D058666:Adrenergic beta-2 Receptor Agonists / Q000008:administration & dosage*; D000368:Aged; D001993:Bronchodilator Agents / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D018727:Muscarinic Antagonists / Q000008:administration & dosage*; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000458:organization & administration*; D029424:Pulmonary Disease, Chronic Obstructive / Q000145:classification* / Q000188:drug therapy*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D006113:United Kingdom
chemical_list: D000305:Adrenal Cortex Hormones; D058666:Adrenergic beta-2 Receptor Agonists; D001993:Bronchodilator Agents; D018727:Muscarinic Antagonists
keywords: GOLD guidelines; chronic obstructive pulmonary disease; observational study; prescribing patterns; primary care