Department of Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.
Chest. 2021 Mar;159(3):975-984. doi: 10.1016/j.chest.2020.09.254. Epub 2020 Oct 2.
Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation.
What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD?
A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort.
Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P < .001] and 1.62 [95% CI, 1.39, 1.90; P < .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group.
In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.
因 COPD 住院的患者通常使用吸入性短效支气管扩张剂治疗，有时会替代他们在门诊使用的长效支气管扩张剂。如果在入院时停用，这些长效吸入器应在出院时重新开始使用；然而，医疗保健的转变有时会导致非故意停药。
在加拿大安大略省，2004 年至 2016 年使用健康管理数据进行的一项回顾性队列研究中，老年 COPD 患者出院后，使用长效抗胆碱能药物（LAMA）和长效β-激动剂和吸入皮质类固醇（LABA-ICS）联合药物的非故意停药风险是多少？
该研究纳入了年龄≥66 岁且连续服用 LAMA 或 LABA-ICS 至少 1 年的 COPD 患者。使用逻辑回归模型确定每个药物队列中住院后药物停药的风险。
在本研究中，共纳入 27613 例出院患者，有 1466 例药物被停用。在连续服用 LAMA 或 LABA-ICS 的 78953 例 COPD 患者中，与社区患者相比，住院患者药物停用的风险更高（调整后的风险比分别为 1.50 [95%CI，1.34-1.67；P<0.001] 和 1.62 [95%CI，1.39,1.90；P<0.001]，LAMA 和 LABA-ICS）。服用 LAMA 的患者住院组停药率为 5.2%，社区组为 3.3%；服用 LABA-ICS 的患者住院组停药率为 5.5%，社区组为 3.1%。
在一项对高度依从 COPD 患者的观察性研究中，住院与长效吸入器停药风险增加相关。这些结果表明，在依从性较差的患者中，停药问题可能更大，应在 COPD 患者和平均依从性的前瞻性队列中进行确认和量化。质量改进工作应重点关注出院后的安全过渡和患者用药核对。
