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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, 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. Abbreviations: 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 airflow 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 2longacting 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 an 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 anal- ysis.

Objective of the Study

The main outcome of the study was appropriate treatment, which was defined as correct pharmacological treatment according to GOLD guidelines 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 (CS) plus LABA for group D. Treatment other than this recommendation in a particular category was defined as inappropriate treatment. Inappropriate processing was 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, and this gives an average age of 68.72 ± 9.97 years. (Table: 1) A female patient; the rest of our series is exclusively male (Table: 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. (Table: 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. (Table: 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 (Table: 3). The average FEV1 in % was 66.52% +/- 21.60; overall, our sample was not obstructive (Table: 4). 62.3% (n=38) of patients in our series have a pH between 7.38 and 7.42. 34.4% (n=21) have a pH > 7.42, and 3.3% (n=2) have a pH < 7.38. 45.9% (n=28) of patients in our series have a PaO₂ between 75 and 100 mmHg; 52.5% (n=32) have a PaO₂ < 75 mmHg. (Table: 4) Patients belonging to categories B and D represent two-thirds of our series, with 26.2% and 39.3% of cases, respectively (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), and 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 Table 3: General parameters 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, 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

Table4: Spirometric and gasometric parameters

Figure1: Classification de la BPCO (GOLD 2022) (en %)

Figure 2: Distribution of patients by treatment at first consultation

Figure3: 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 overutilization may be explained by the choice of treating physicians who believe it is more effective for patients. Long-acting bronchodilators (sanas associated with inhaled corticosteroids) are prescribed in 52.5% of patients, with a more frequent prescription for LABA (21.3%) versus LAMA (8.2%) and LABA+LAMA (23%); this may be due to the unavailability and cost of LAMA. (Table-5) The ICS alone are not prescribed in patients of our population, likewise for phosphodiesterase 4 inhibitors and theophylline. Whereas fixed associations were found 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 over-treatment 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. (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. (2017) [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 by Foda, Hussein D., et al. [16] of 878 patients with spirometry-confirmed COPD found that about 19% were treated appropriately by guidelines, 14% were overtreated, and 44% were 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 suboptimal adherence to the guidelines.

Conclusions

Failure to follow the GOLD guidelines for COPD 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 insufficientassessment 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 ics 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 au- thors 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.

References

1. Agustí, Alvar, Bartolome R. Celli, Gerard J. Criner, David Halpin, Antonio Anzueto, Peter Barnes, Jean Bourbeau et al. "Global initiative for chronic obstructive lung disease 2023 report: GOLD executive summary." Journal of the Pan African Thoracic Society 4, no. 2 (2022): 58-80.
   View at Publisher | View at Google Scholar
2. Carette, H., M. Zysman, C. Morelot-Panzini, J. Perrin, E. Gomez, A. Guillaumot, P. R. Burgel et al. "Prevalence and management of chronic breathlessness in COPD in a tertiary care center." BMC pulmonary medicine 19, no. 1 (2019): 95.
   View at Publisher | View at Google Scholar
3. Raherison, Chantal, and PIERRE‐OLIVIER Girodet. "Epidemiology of COPD." European respiratory review 18, no. 114 (2009): 213-221.
   View at Publisher | View at Google Scholar
4. Adeloye, Davies, Stephen Chua, Chinwei Lee, Catriona Basquill, Angeliki Papana, Evropi Theodoratou, Harish Nair et al. "Global and regional estimates of COPD prevalence: Systematic review and meta–analysis." Journal of global health 5, no. 2 (2015): 020415.
   View at Publisher | View at Google Scholar
5. Buist, A. S., W. M. Vollmer, and M. A. McBurnie. "Worldwide burden of COPD in high-and low-income countries. Part I. The Burden of Obstructive Lung Disease (BOLD) Initiative [State of the Art Series. Chronic obstructive pulmonary disease in high-and low-income countries. Edited by G. Marks and M. Chan-Yeung. Number 6 in the series]." The international journal of tuberculosis and lung disease 12, no. 7 (2008): 703-708.
   View at Publisher | View at Google Scholar
6. Tageldin, Mohamed Awad, Salim Nafti, Javaid Ahmed Khan, Chakib Nejjari, Majed Beji, Bassam Mahboub, Nathir M. Obeidat et al. "Distribution of COPD-related symptoms in the Middle East and North Africa: results of the BREATHE study." Respiratory medicine 106 (2012): S25-S32.
   View at Publisher | View at Google Scholar
7. TO, POCKET GUIDE. "Global initiative for chronic obstructive lung." Am J Respir Crit Care Med 197, no. 1 (2018): 10-1164.
   View at Publisher | View at Google Scholar
8. Cazzola, Mario, and Maria Gabriella Matera. "Long-acting bronchodilators are the first-choice option for the treatment of stable COPD." Chest 125, no. 1 (2004): 9-11.
   View at Publisher | View at Google Scholar
9. Vogelmeier, Claus, Peter Kardos, Sergio Harari, Steven JM Gans, Stephan Stenglein, and Jackie Thirlwell. "Formoterol mono-and combination therapy with tiotropium in patients with COPD: a 6-month study." Respiratory medicine 102, no. 11 (2008): 1511-1520.
   View at Publisher | View at Google Scholar
10. Bateman, Eric D., Gary T. Ferguson, Neil Barnes, Nicola Gallagher, Yulia Green, Michelle Henley, and Donald Banerji. "Dual bronchodilation with QVA149 versus single bronchodilator therapy: the SHINE study." European Respiratory Journal 42, no. 6 (2013): 1484-1494.
    View at Publisher | View at Google Scholar
11. Antón, Esther. "How and when to use inhaled corticosteroids in chronic obstructive pulmonary disease?." Expert Review of Respiratory Medicine 7, no. sup2 (2013): 25-32.
    View at Publisher | View at Google Scholar
12. Suissa, S., and P. J. Barnes. "Inhaled corticosteroids in COPD: the case against." European Respiratory Journal 34, no. 1 (2009): 13-16.
    View at Publisher | View at Google Scholar
13. Price, David, Barbara Yawn, Guy Brusselle, and Andrea Rossi. "Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD." Primary Care Respiratory Journal 22, no. 1 (2013): 92-100.
    View at Publisher | View at Google Scholar
14. Miravitlles M, Soler-Cataluña JJ, Calle M, Molina J, Almagro P, Quintano JA, et al. A new approach to grading and treating COPD based on clinical phenotypes: summary of the Spanish COPD guidelines (GesEPOC). Primary Care Respiratory Journal. 2013;22(1):117-21.
    View at Publisher | View at Google Scholar
15. Corrado, Antonio, and Andrea Rossi. "How far is real life from COPD therapy guidelines? An Italian observational study." Respiratory medicine 106, no. 7 (2012): 989-997.
    View at Publisher | View at Google Scholar
16. Foda HD, Brehm A, Goldsteen K, Edelman NH. Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD. International journal of chronic obstructive pulmonary disease. 2017:209-14.
    View at Publisher | View at Google Scholar
17. Bettoncelli, Germano, Francesco Blasi, Vito Brusasco, Stefano Centanni, Antonio Corrado, Fernando De Benedetto, Fausto De Michele et al. "The clinical and integrated management of COPD. An official document of AIMAR (interdisciplinary association for research in lung disease), AIPO (Italian association of hospital pulmonologists), SIMER (Italian society of respiratory medicine), SIMG (Italian society of general medicine)." Multidisciplinary respiratory medicine 9, no. 1 (2014): 25.
    View at Publisher | View at Google Scholar
18. Hashimoto, Naozumi, Keiko Wakahara, and Koji Sakamoto. "The importance of appropriate diagnosis in the practical management of chronic obstructive pulmonary disease." Diagnostics 11, no. 4 (2021): 618.
    View at Publisher | View at Google Scholar
19. Roche, Nicolas, Vicente Plaza, Vibeke Backer, Job van der Palen, Isa Cerveri, Chelo Gonzalez, Guilherme Safioti, Irma Scheepstra, Oliver Patino, and Dave Singh. "Asthma control and COPD symptom burden in patients using fixed-dose combination inhalers (SPRINT study)." NPJ primary care respiratory medicine 30, no. 1 (2020): 1.
    View at Publisher | View at Google Scholar
20. Price, David, Daniel West, Guy Brusselle, Kevin Gruffydd-Jones, Rupert Jones, Marc Miravitlles, Andrea Rossi et al. "Management of COPD in the UK primary-care setting: an analysis of real-life prescribing patterns." International journal of chronic obstructive pulmonary disease (2014): 889-905.
    View at Publisher | View at Google Scholar
21. Palmiotti, Giuseppe Antonio, Donato Lacedonia, Vito Liotino, Pietro Schino, Francesco Satriano, Pier Luigi Di Napoli, Eugenio Sabato et al. "Adherence to GOLD guidelines in real-life COPD management in the Puglia region of Italy." International journal of chronic obstructive pulmonary disease (2018): 2455-2462.
    View at Publisher | View at Google Scholar
22. Chan KP, Ko FW, Chan HS, Wong ML, Mok TY, Choo KL, et al. Adherence to a COPD treatment guideline among patients in Hong Kong. International journal of chronic obstructive pulmonary disease. 2017:3371-9.
    View at Publisher | View at Google Scholar
23. Tongdee, Sukanya, Bundit Sawunyavisuth, Wattana Sukeepaisarnjaroen, Watchara Boonsawat, Sittichai Khamsai, and Kittisak Sawanyawisuth. "Clinical factors predictive of appropriate treatment in COPD: a community hospital setting." Drug Target Insights 15 (2021): 21.
    View at Publisher | View at Google Scholar
24. Perez, Xavier, Juan P. Wisnivesky, Linda Lurslurchachai, Lawrence C. Kleinman, and Ian M. Kronish. "Barriers to adherence to COPD guidelines among primary care providers." Respiratory medicine 106, no. 3 (2012): 374-381.
    View at Publisher | View at Google Scholar
25. Overington, Jeff D., Yao C. Huang, Michael J. Abramson, Juliet L. Brown, John R. Goddard, Rayleen V. Bowman, Kwun M. Fong, and Ian A. Yang. "Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions." Journal of thoracic disease 6, no. 11 (2014): 1586.
    View at Publisher | View at Google Scholar