Cleveland, OH—Inhaled corticosteroids (ICS) are overused in chronic obstructive pulmonary disease (COPD), according to a new study seeking to better understand why primary-care providers so often diverge from clinical guidelines.

The article published in the Journal of General Internal Medicine points out that more than half of Department of Veterans’ Affairs patients diagnosed with mild-to-moderate COPD are prescribed ICS, despite recommendations for use restricted to patients with frequent exacerbations.

In an effort to better understand the process of prescribing for COPD, VA Northeast Ohio Healthcare System–led researchers conducted a quality improvement initiative and documented primary-care providers’ experiences prescribing ICS among patients with mild-to-moderate forms of the disease.

The study team used a sequential mixed-methods evaluation approach to understand factors influencing primary-care providers’ ICS prescribing for patients with nonsevere COPD. The authors recruited healthcare providers from 13 primary-care clinics affiliated with two urban Veterans’ Health Administration systems to participate in qualitative interviews and structured surveys. Interviews were transcribed and analyzed using content analysis.

Results indicated that many participants reported they were unaware of current evidence and recommendations for prescribing ICS. Researchers explained that, “for example, 46% of providers reported they were unaware of risks of pneumonia.”

The providers also revealed that they often are unable to keep up with the current literature due to the broad scope of primary-care practice, the authors write, adding, “We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate.”

The researchers conclude, “Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers’ lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.”

In agreement with current evidence, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy recommends limiting ICS use as part of initial treatment for COPD group D patients with two or more moderate exacerbations or one exacerbation leading to hospitalization in the preceding year and a blood eosinophil count greater than 300 cells/µL. The therapy also is appropriate as part of follow-up treatment in COPD patients with persistent exacerbations on long-acting bronchodilator monotherapy or in LABA/LAMA combination therapy and with a blood eosinophil count greater than 100 cells/µL, according to a study this summer in the International Journal of Chronic Obstructive Pulmonary Disease.

Those authors caution that use of ICS in COPD patients is associated with a number of adverse events, including increased risks of pneumonia, tuberculosis, and nontuberculous mycobacterial infections, osteoporosis, and bone fracture, as well as poor diabetes control. Local reactions include oral candidiasis, hoarseness, and cough.

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