Deprescribing of high-dose inhaled corticosteroids in COPD with mild or moderate airflow limitation: what do patients think?

Problem

High-dose inhaled corticosteroids (HD-ICS) are often prescribed inappropriately in COPD patients with mild or moderate airflow limitation. HD-ICS increase pneumonia risk and other complications in patients with COPD. Most inappropriate prescribing of HD-ICS for COPD takes place in primary care. Patients who are inappropriately prescribed HD-ICS should undergo a trial of withdrawal. Deprescribing is complex in patients given the medication to provide long-term prevention and who may feel the medication is helping. In this study we gathered the views on staged deprescribing of HD-ICS in COPD patients with mild or moderate airflow limitation who were taking the medication.

Approach

Participants were recruited from the COPD registers of general practices using an electronic search of records. They had to have a diagnosis of COPD confirmed by spirometry at interview, no evidence of asthma, no evidence of severe or very severe airflow limitation, and to be currently prescribed HD-ICS. One-to-one semi-structured qualitative interviews were carried out exploring COPD patients’ opinions and feelings about using HD-ICS prescribed outside guidelines and their attitudes to proposed withdrawal. Interviews were audio-recorded and transcribed verbatim. Data were processed using NVivo and thematic analysis was completed.

Findings

Twenty-four COPD patients were interviewed. Six did not meet spirometric eligibility criteria. Seventeen interviews were included. Many participants were not aware they were using a HD-ICS, did not know the medication was prescribed as a preventative, and did not know of the risk of side effects. Some were unconcerned by what they perceived as low risk, others expressed fears of worsening symptoms on withdrawal. Most would have been willing to attempt withdrawal or titration to a lower dose of HD-ICS if advised by their clinician. Some would have accepted their clinician’s advice without question, but many would have been more willing to accept deprescribing if a reasoned explanation was offered.

Consequences

Attitudes to deprescribing of inappropriately prescribed HD-ICS in COPD were varied. Ignorance of the indication, the fact that the medication contained steroids and its potential side effects, was surprising to many participants. Deprescribing of these drugs is likely to be required in general practice. Primary care clinicians managing COPD should be aware of the range of patients' issues that may need to be addressed in undertaking this work.