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| Trends
in the Usage of Asthma and COPD Drugs in England (Chart
1) |
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| Charts
1 and 2 illustrate National trends in the prescribing
of drugs used to treat asthma and chronic obstructive
pulmonary disease (COPD). In terms of both usage and costs
respiratory prescribing is one of the top 4 BNF chapters.
There is a seasonal trend, with the quarter to December
always having the greatest usage. |
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| Treatment
of asthma often receives more media attention than treatment
of COPD however COPD is a major cause of morbidity. Patients
with COPD make greater use of both GP and hospital services
than patients with asthma. In 1992 6.4% of all male and
3.9% of all female deaths in England and Wales were attributed
to COPD, chronic bronchitis or emphysema, 26,033 deaths
in total compared to 1,791 asthma deaths. 1
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| Cigarette
smoking is the single most important cause of COPD: the
greater the consumption of cigarettes the higher the risk
of developing COPD.1 About 15% of people smoking cigarettes
at the rate of one pack per day and 25% of those smoking
two packs per day go on to develop COPD if they continue
their habit.2 COPD is rare in lifetime non-smokers and
some of the possible explanations for the occurrence of
COPD in non-smokers are: exposure to environmental tobacco
smoke (passive smoking), airway hyperresponsiveness, ambient
air pollution and allergy.1 |
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| The
diagnosis of COPD is usually suggested by the presenting
symptoms but it can only be established by objective measurements.1
Spirometry is the investigation of choice for assessing
severity, reversibility and the effects of treatment.2
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| Trends
in Spending on Asthma and COPD Drugs in England (Chart
2) |
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| Only
two interventions have been found to alter the long term
course of COPD - smoking cessation and long term oxygen
therapy (LTOT) in severe hypoxaemia. Stopping smoking
is the single most important way of affecting outcome
in patients at all stages of COPD.1 It cannot
restore the loss of lung function but can prevent the
accelerated decline seen in many COPD patients.1
The use of nicotine replacement therapy along with smoking
cessation advice doubles the success rate of a quit attempt.
Buproprion is now available on FP10 and there is some
evidence to suggest it is highly effective for smoking
cessation. |
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| LTOT
improves survival in selected patients with severe COPD
and chronic hypoxaemia. Continuous treatment is more effective
than nocturnal treatment. It is recommended that a respiratory
physician assesses all patients considered for LTOT and
arterial blood gas tensions should be measured.1 LTOT
involves a minimum of 15 hours oxygen per day and whenever
possible this should be provided by means of an oxygen
concentrator.1 |
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Drug
therapy does not alter the long term course of COPD.
Inhaled beta-agonists or antimuscarinic drugs can offer
short term benefit and the combined use of these agents
has been found to be more effective than using either
alone.3 There have been several studies looking
at the place of inhaled corticosteroids in COPD. The
findings from these studies are rather contradictory
and generally do not support the use of inhaled steroids,
although there is some suggestion from a recent trial
that they may improve quality of life and reduce exacerbation
in those with more severe COPD.3
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| Variation
Between Health Authorities in Antimuscarinic Prescribing
(October to December 1999 - Chart 3) |
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| The
British Thoracic Society (BTS) guidelines recommend the
use of antibiotics in acute exacerbations of COPD if at
least two of the following are present: increased breathlessness,
increased sputum volume, development of purulent sputum.1
The choice of antibiotic will depend on local microbiological
guidelines.1 |
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| Trials
of short term treatment with theophyllines have shown
varying effects on forced expiratory volume (FEV1), exercise
capacity and symptoms. Theophyllines frequently produce
adverse effects within the therapeutic range.3
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| Vaccination
against influenza is recommended for patients with moderate
to severe COPD.2 On 23 May 2000 the Health Secretary announced
that influenza vaccine would now be offered to all people
aged 65 years and over. |
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| Unless
otherwise stated the following prescribing data compare
the quarter to December 1994 with the quarter to December
1999. |
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| Beta-agonists
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| The
use of beta-agonists has increased by 14% over the last
5 years to 200 million DDDs, whilst costs have risen by
43% to £48 million. The use of salbutamol has increased
and it remains the most frequently used beta-agonist at
159 million DDDs. The use of salmeterol has more than
doubled over the last 5 years and is now 11% of beta-agonist
use, 21 million DDDs. Although the use of salmeterol is
low compared to salbutamol, costs are very similar, 46%
or £22 million for salbutamol and 43% or £20 million for
salmeterol. |
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| The
use of terbutaline has started to decline and is now 9%
of beta-agonist use. Beta-agonists are given by a variety
of different means. Plain metered dose inhalers (MDI)
are the most popular (72% of use and 54% of costs). Breath
actuated MDIs constitute 7% of the use and 8% of costs,
with dry powder devices 17% of use and 27% of costs and
nebuliser solutions 3% of use and 8% of costs. Administration
of bronchodilators by MDI plus spacer relieves acute asthma
at least as effectively as administration from a nebuliser.
Nebulisers should only be supplied for patients who have
been assessed fully by a respiratory physician.1
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| Antimuscarinic
bronchodilators |
| Use
of antimuscarinic bronchodilators has increased by 16%
and is now just over 32 million DDDs. Ipratropium accounts
for 96% of this usage with 55% prescribed as MDIs, 40%
as nebuliser solution and less than 1% as dry powder devices.
The use of oxitropium has fallen to 1.4 million DDDs.
The cost of antimuscarinic bronchodilators has risen by
6% to £6 million, 56% of these costs are ipratropium nebuliser
solution (£3.4 million). |
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| Compound
bronchodilator preparations |
| The
use of compound combined preparations of fenoterol with
ipratropium has fallen over the last 5 years by 34% to
under 3 million DDDs, costing £700,000. By contrast the
use of combined preparations of salbutamol with ipratropium
has risen dramatically since their introduction early
in 1994, their use is now 8 million DDDs and they cost
£5 million. |
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| Chart
3 shows the variation between health authorities in the
prescribing of antimuscarinic bronchodilators, both single
(ipratropium or oxitropium alone) and compound (ipratropium
plus salbutamol or fenoterol). Overall there is a 7-fold
variation across the English health authorities with higher
prescribing in the North and lower prescribing mainly
in the London area. Breaking this down the prescribing
of single antimuscarinics shows a 6-fold variation whilst
the prescribing of the compound bronchodilators shows
a 54-fold variation. In one health authority just 7% of
prescribing is for compound preparations whilst at the
other extreme in another health authority it is 72%. |
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| Theophylline
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| Overall
use of theophylline and aminophylline has fallen by around
29% to 12 million DDDs, at a cost of £1.7 million. There
is slightly more use of theophylline at 7 million DDDs
compared to aminophylline at 5 million DDDs. |
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| Inhaled
corticosteroids |
| Inhaled
corticosteroids should be mainly used in asthma. A corticosteroid
trial could be considered in patients presenting with
moderate or severe COPD. Use of inhaled corticosteroids
has increased by 37% over the last 5 years to 147 million
DDDs at a cost of £74 million. Beclomethasone usage is
greatest (105 million DDDs, 71%), at a cost of £38 million
(52%). Use of fluticasone (23 million DDDs, 16%) and budesonide
(19 million DDDs, 13%) are lower, with a cost of £21 million
(28%) and £15 million (20%) respectively. |
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| Again
plain MDIs are the most popular at 73% of use, 59% of
costs. Breath actuated MDIs have a usage of 8%, 6% costs.
Dry powder devices are 18% of the usage and 29% of costs.
Only 1% of the usage is for nebuliser solutions but this
is 6% of costs. |
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| Cost
for 28 Days Treatment |
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| Cromoglycate,
related therapy and leukotriene receptor antagonists These
are normally used in asthma. Cromoglycate, nedocromil
and ketotifen use has fallen from 5 million DDDs to 1.3
million DDDs, at a cost of £1.4 million. Sodium cromoglycate
remains the most frequently prescribed. |
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| Leukotriene
receptor antagonists were introduced early in 1998 and
their usage is now 2.5 million DDDs at £2.4 million. Montelukast
is the most frequently prescribed. |
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| Oxygen
cylinders Prescribing of oxygen cylinders has increased
over the last 5 years from 108,000 prescriptions to 139,000
prescriptions costing £2 million per quarter. Smaller,
portable 300L cylinders have shown the largest increase
in prescribing from 2% of all cylinders prescribed to
13%. It is cost effective to prescribe an oxygen concentrator
for patients who require 21 cylinders or more per month.2
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References
and Further Reading
1. BTS guidelines for the management of COPD, Thorax
1997; 52 (Suppl 5): S1-S28
2.
PRODIGY COPD guidelines - www.prodigy.nhs.uk
3.
Kerstjens, Postma. COPD. Clinical Evidence Issue 3,
BMJ Publishing Group, June 2000.
4.
The Management of COPD, MeReC Bulletin Volume 9, Number
10, 1998
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Summary
-
Cigarette smoking is the single most important
cause of COPD and support for stopping smoking
should be given to all patients.
- Long
term oxygen therapy improves survival in selected
patients with severe COPD and chronic hypoxaemia.
- Inhaled
beta-agonists or antimuscarinic drugs can offer
short term benefit in COPD and their combined
use is more effective than either drug alone.
- Remember
influenza vaccination for moderate to severe
COPD as well as for all patients over 65 years.
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