title: An evaluation of early medication use for COPD: a population-based cohort study.
abstract: OBJECTIVE
  The aim of this study was to evaluate the first initiation, sequence of addition, and appropriate prescribing of COPD medications in Manitoba, Canada.
  
  
  METHODS
  A population-based cohort study of COPD medication use was conducted using administrative health care data (1997-2012). Those aged ≥35 years with COPD based on three or more COPD-related outpatient visits over a rolling 24-month window or at least one COPD-related hospitalization were included. The first medication(s) dispensed on or after the date of COPD diagnosis were determined based on pharmacy claims. The next medication(s) in sequence were determined to be additions or switches to the previous regimen. Evaluation of guideline-based appropriateness to receive inhaled corticosteroids (ICS) was based on exacerbation history and past medication use.
  
  
  RESULTS
  Of 13,369 patients dispensed COPD medications after diagnosis, 66.0% were dispensed short-acting bronchodilators as first medications. Although long-acting bronchodilators alone were uncommonly used as first or subsequent medications, ICS were dispensed as first medications in 28.2% of patients. Over the study period, use of short-acting bronchodilators as first medications declined from 70.6% to 59.4% (P<0.0001), whereas the use of ICS as a first medication increased from 23.5% to 34.4% (P<0.0001). Dispensation of an ICS plus a long-acting β-agonist increased dramatically from 1.2% to 27.3% (P<0.0001). By the end of the study period, the majority of patients (53.3%) were being initiated on two or more medications. Of 5,823 patients dispensed an ICS, 52.4% met Canadian guideline criteria for initiating an ICS, whereas 0.3% met Global Initiative for Chronic Obstructive Lung Disease guideline criteria.
  
  
  CONCLUSIONS
  The use of first-line medications has declined over time, replaced primarily by combination inhalers prescribed early without prior trials of appropriate next step medications. This, along with an increasingly predominant use of multiple first medications, indicates a significant degree of medication burden in this already complex patient population.
authors.affiliation: College of Pharmacy, Rady Faculty of Health Sciences.
authors.forename: Jamie
authors.initials: J
authors.lastname: Falk
authors.affiliation: Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
authors.forename: Natalia
authors.initials: N
authors.lastname: Dik
authors.affiliation: College of Pharmacy, Rady Faculty of Health Sciences.
authors.forename: Shawn
authors.initials: S
authors.lastname: Bugden
mesh_terms: D000280:Administration, Inhalation; D000067575:Administrative Claims, Healthcare; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D058666:Adrenergic beta-2 Receptor Agonists / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D001993:Bronchodilator Agents / Q000008:administration & dosage*; D016208:Databases, Factual; D004334:Drug Administration Schedule; D004338:Drug Combinations; D011307:Drug Prescriptions; D057915:Drug Substitution; D004359:Drug Therapy, Combination; D017723:Drug Utilization Review; D061345:Early Medical Intervention; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D057970:Inappropriate Prescribing; D008137:Longitudinal Studies; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D008297:Male; D008350:Manitoba; D008875:Middle Aged; D009330:Nebulizers and Vaporizers; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D058666:Adrenergic beta-2 Receptor Agonists; D001993:Bronchodilator Agents; D004338:Drug Combinations
keywords: COPD; Canada; appropriate; guideline; inhaled steroids; medication