Medires Publishers - Article

Abstract

Despite the availability of national and international recommendations, it should be noted that treatment of chronic obstructive pulmonary disease (COPD) does not always follow the recommendations.
This study evaluated the current management of patients with COPD at their first visit to the Pulmonology Service consultation. Constantine Regional Military University Hospital
Methods
Sixty-one consecutive patients with spirometry-confirmed stable COPD were included after obtaining informed written consent. Demographic and clinical data, spirometric values, 6-minute walking distance, BMI and current treatment were collected for analysis.
This is a prospective study conducted at Constantine Regional Military University Hospital
Results
Long-acting bronchodilators without inhaled corticosteroids were prescribed in 52.5% of patients, with a preference for LABA (21.3%) over LAMA (8.2%). The combination LABA + LAMA was used in 23% of patients. The unavailability and cost of LAMA could explain this difference in prescription.
Inhaled corticosteroids were used by 39.3% of patients, with overrepresentation in B and D (66.66%).
None of our patients received inhaled corticosteroids alone, or PDE4 inhibitors or theophylline
At the time of the first consultation, 93.4% of our cohort patients were on treatment for COPD. Among those not treated, the majority were in the mild (75%) and moderate (25%) severity groups. Approximately 26.2% of patients received a combination of short-acting bronchodilators (SABA) + two long-acting bronchodilators (LABA + LAMA) + inhaled corticosteroids (IC), with higher prevalence in the most symptomatic groups (B and D), 75%.
Conclusions
The guidelines were not followed in their great majority, so COPD is not treated according to the recommendations of the GOLD, it happens that some patients do not receive any treatment despite the emergence of symptoms.
ICS are commonly administered to patients under treatment, regardless of the severity of airflow limitation.
Abréviations: CAT, COPD Assessment Test ; BPCO, maladie pulmonaire obstructive chronique
; VEMS , volume expiratoire maximal en 1 seconde ; GOLD, Global Initiative for Chronic Obstructive Lung Disease ; mMRC, Medical Research Council modifié, corticostéroïdes inhalés (CSI), bêta2- agonistes à action prolongée : (LABA) antagoniste muscarinique à action prolongée :( LAMA)

Introduction

Chronic obstructive pulmonary disease (COPD) is a complex disease characterized by pulmonary and extrapulmonary effects. Since air flow limitation is not closely related to other important clinical outcomes of COPD
GOLD 2022 defines COPD as a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, expectoration and/or exacerbations) due to airway abnormalities (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction,COPD is a major public health problem and is a leading cause of chronic morbidity and mortality worldwide.(1)
Prevalence of COPD is difficult to assess because it requires patient cohorts representative of the entire population using spirometric measurements (2)
Studies have shown a wide geographic disparity in COPD prevalence (3). This is due to differences in survey methods, diagnostic criteria and target populations.An estimated 384 million people had COPD in 2010 and the global prevalence is estimated at 11.7% (8.4% - 15.0%) in 2015(4).
According to the BOLD study:10.1% of people over 40 have COPD (5). In Algeria, according to the results of the Breathe study, COPD prevalence is estimated at 4% in the general population and 25% among smokers(6).
The goal of the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD)2022 is to jointly assess current symptoms and future risk of exacerbations. Pharmacological therapy in COPD is used to reduce clinical signs, reduce the frequency and severity of symptoms, and promote health status and exercise tolerance.(7) Bronchodilators are essential for the pharmacological management of COPD(1), Short-acting bronchodilators are used to relieve symptoms immediately, one or more long-acting bronchodilators (β 2-long-acting agonists [LABA] or long-acting muscarinic antagonists [LAMA]) are recommended for long-term maintenance treatment in people with moderate to severe COPD.(8) There is an approach to improve efficacy by combining various bronchodilators with different pharmacological classes without increasing the risk of side effects, compared to increasing the dose from a single bronchodilator.(9, 10)
Although inhaled corticosteroids (ICS) are essential for treating asthma, their role in COPD remains controversial.(11) The benefit from the ICS component appears small compared to that of the LABA component(12, 13), In addition, the use of CIs has been associated with local and systemic side effects, including skin thinning and easy bruising,oral candidiasis, increased risk of pneumonia, osteoporosis, early onset diabetes, cataracts and tuberculosis.
However, evidence suggests that treatment is not always prescribed in accordance with GOLD recommendations or other national guidelines(14, 15), This unnecessarily and unjustifiably exposes a large proportion of patients treated with ICS to the risk of serious side effects.
nder-treatment as directed increases the risk of COPD exacerbation with a coefficient of 0.179 (p < 0.001) (16)
The control of COPD may be influenced by several factors, such as the severity of COPD, patient adherence to treatment, appropriate inhalation technique or non- pharmacological treatment.(17, 18) , and although patients with COPD had a 51.0% adherence to treatment, only 15.5% were under control (19)
The objective of this study was to evaluate the current management of patients with COPD, during their first visit to the consultation

Methods

Patients with confirmed COPD with a FEV1/FVC ratio <70% after bronchodilator and followed up in the Pulmonology Department of the Constantine Regional Military University Hospital (HMRUC).
Sixty-one consecutive stable COPD patients were included after obtaining written informed consent. Demographic and clinical data, spirometric values, 6-minute walking distance, BMI , les comorbidités standard de la BPCO, l'historique des exacerbations and traitement actuel were collected for analysis.

Objective of the Study

The main outcome of the study was appropriate treatment, which was defined as correct pharmacological treatment according to GOLD guideline for categories A through D: a bronchodilator for group A; a long-acting bronchodilator (long-acting beta-2-agonists: LABA or long-acting muscarinic antagonist: LAMA) for group B; LAMA for group C; and LAMA or LAMA plus LABA or inhaled corticosteroid (CSI) more LABA for group
D. Treatment other than this recommendation in a particular category was defined as inappropriate treatment. Inappropriate processing was also classified as under-processing and over-processing according to the recommendation for each category.
Note that the information collected for the study was obtained during the initial treatment of each patient.

The results

In our series the minimum age is 43 years, the maximum age is 84 years, this gave an average age of 68.72 ± 9.97 years. (Tabl: 1)
A female patient, the rest of our series is exclusively male (Tabl: 2)
In this cohort, an IMC was calculated using the following formula: IMC = weight/tail2 expressed in kg/m2, Based on our results, the average BMI is 24.12 +/- 4.83 kg/m2 with extremes ranging from 14.6 to 36.9 kg/m2 (Tabl: 3)
The median CAT score of our population is 14 +/-6.75 with extremes ranging from 4 to 30, 67.2% of our patients have a CAT score greater than or equal to 10 (Tabl: 3)
Our study found an average consumption of 41.54 +/- 17.93 packets/year. It is 42.29 +/- 10.32 for current smokers versus 43.16 +/- 18.05 p/year for former smokers (Tabl: 3)
The average FEV1 in % was 66.52%+/- 21.60, overall our sample was not obstructive (Tabl: 4)
62,3 % n(38) patients in our series have a PH between 7,38 et 7,42, 34,4 % n(21) ont un pH > 7,42 et 3,3 % n(2) ont un pH < 7,38 ,45,9% n(28) Patients in our series have a PaO2 between 75 et 100 mmHg, 52,5% n(32) ont une PaO2 < 75 mmHg (Tabl: 4)
Patients belonging to categories B and D represent two-thirds of our series with respectively 26.2% and 39.3% of cases (figure :1)
At the time of the first consultation, 93.4% of our cohort patients were on treatment for COPD (Figure 2). Among those not treated, the majority were in the mild (75%) and moderate (25%) severity groups. Approximately 26.2% of patients received a combination of short-acting bronchodilators (SABA) + two long-acting bronchodilators (LABA + LAMA) + inhaled corticosteroids (IC)(Figure 2), with higher prevalence in the most symptomatic groups (B and D), 75%.
Inhaled corticosteroids were used by 39.3% of patients, with overrepresentation in B and D (66.66%).
Long-acting bronchodilators without inhaled corticosteroids were prescribed in 52.5% of patients, with a preference for LABA (21.3%) over AML (8.2%). The combination LABA + LAMA was used in 23% of patients. The unavailability and cost of LMAMs could explain this difference in prescription.
None of our patients received inhaled corticosteroids alone, or d'inhibiteurs de la phosphodiestérase 4 or theophylline (Figure 2)
In our cohort, 47.5% of patients received treatment in accordance with GOLD recommendations, while 26.2% were undertreated and 26% overtreated,(Figure 3)with a marked overprescription of inhaled corticosteroids, especially in patients in groups A and B, that do not require such treatments according to the guidelines.
If we apply a readjustment of treatment in our patients according to the recommendations of GOLD, we obtain : (Table 6)
patient under treatment :SABA + LABA (27,9%)
patient under treatment :SABA + LABA + LAMA (42,6%) patient under treatment :SABA + LABA + LAMA + CI (29,5%)
Table1:  Age distribution

Table2: Distribution by gender

Table 3: General parameters

FIG1: Classification de la BPCO (GOLD 2022) (en %)

Fig 2: Distribution of patients by treatment at first consultation

Table 5: ABCD First Consultation Treatment

Fig3: Percentage of patients by therapeutic status

Table 6: Distribution of patients on readjustment according to the ABCD classification

Discussion

During the first consultation 39.3% of patients use inhaled corticosteroids, and the majority (66.66%) belong to the most symptomatic groups (B, D) GOLD, the Italian study by Palmiotti, Giuseppe Antonio, et al also found that inhaled corticosteroids were overused despite GOLD guidelines not recommending it, Inappropriate use of inhaled corticosteroids was also reported in 50% of COPD patients in the UK(20). this over-utilization may be explained by the choice of treating physicians who believe it is more effective for patients.
Long-acting bronchodilators (sanas association with inhaled corticosteroid) are prescribed in (52.5%) of patients, with a more frequent prescription for LABA (21.3%) versus (8.2%) for LAMA and (23%) for LABA + LAMA; this may be due to unavailability and cost of the LAMA. (Table 5)
The ICS alone are not prescribed in patients of our population, likewise for phosphodiesterase 4 inhibitors, and theophylline. Whereas fixed associations in 39.3% of patients
In 2018, Palmiotti, Giuseppe Antonio, et al.(21)Showed that the most used inhaled drugs were LMAT (72.6%), LABA (67.3%) and SCI (49.8%). Only (0.9%) used phosphodiesterase 4 inhibitors, while (5.3%) used theophylline.
In our cohort, during the first consultation The appropriate treatment of COPD patients according to the GOLD guidelines was 47.5%, 26.2% are under-treated and 26% over-treated ( A significant proportion of overtreatment was due to the use of CSI alone or in combination with BALTs in patients in groups A and B.), this study had an appropriate rate of treatment comparable to that of the study conducted Chan, Ka Pang, et al. in 2017 (22)showed in their study that adherence to pharmacological treatment guidelines ranged from 47.7% to 58.1% during the three 12-month clinical visits with over-prescription of inhaled corticosteroids
Tongdee, Sukanya, et al. (23) Concluded that the appropriate treatment for COPD patients under the GOLD guidelines was 26.47% in a community setting.
A recent study in the United States Foda, Hussein D., et al (16) of 878 patients with spirometry-confirmed COPD; about 19% were treated appropriately by guidelines; 14% were overtreated, 44% undertreated
Quant'a Palmiotti, Giuseppe Antonio, et al.(21) about 60.46% were treated appropriately by the guidelines; 29.58% not treated properly, 9.96% not treated
Reasons such as poor knowledge of GOLD guidelines and difficulties in assessing response to treatment may contribute to sub-optimal adherence to the guidelines.

Conclusions

treatment can be attributed to a number of factors, including poor knowledge of recommendations, time constraints or lack of awareness by physicians. It may also be related to insufficient assessment of patients' symptoms and inadequate understanding of recommended treatment protocols. Our study showed that the main cause of overtreatment was excessive use of inhaled corticosteroids (ICS) in low-risk patients, especially in groups A and B, where these drugs are generally not indicated. Long-acting bronchodilators, recommended for patients in groups A and B, were underused, with a preference for the LABA/CSI combination rather than for LAMA or LABA monotherapy. The popularity of LABA/CSI associations could be explained by their availability and long market presence, making them more accessible in the public health system.
Theophylline, although a cheap bronchodilator, is rarely prescribed because of its systemic side effects. Roflumilast, a phosphodiesterase 4 inhibitor, is not used in our population despite its indication for patients in groups C and D due to its high cost and unavailability.
To improve adherence to the GOLD guidelines, several strategies have been proposed around the world with varying results (24, 25). Unfortunately, in Algeria, there is little data available on adherence to therapeutic recommendations, justifying the need for additional studies to optimize COPD management and improve patient outcomes.

Statement

There is no conflict of interest among co-authors.
The authors confirm that an institutional or independent ethics committee has approved the study and informed consent was obtained from the donor
Consent to publication acquired Availability of supporting data
The authors state that there was no funding for this manuscript
-    Contributions from authors:
A. Meridj, Designed and developed the analysis; Written the article.
R. Belala, Collected data;
K. Tlili,  Contributed to data or analytics tools;
Y. Djeghri Conducted the analysis;
-    Thanks: I thank Pr Y. Djeghri for all the efforts made to complete this work
 

Declaration of competing interests

There are no competing interests in the manuscript, the authors explicitly state this: “The authors declare that they have no conflict of interest.”

Information on the financing

all authors declare that there is no financial or other substantial conflict of interest that could be interpreted as affecting the results or interpretation of the manuscript.

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