Triple Therapy Pathways: A Multi-Country, Retrospective Observational Study in Chronic Obstructive Pulmonary Disease (COPD)

Background: Maintenance treatment in COPD recommends triple therapy (TT), often following use of mono-or dual-therapy. We explored how pathways to TT vary across countries. Aims and Objectives: We investigated the proportion of patients on TT relative to the timing of their COPD diagnosis and the treatment pathway to TT including the time from diagnosis to initiation of TT and adherence. Methods: A retrospective cohort study was performed using anonymised patient-level data from UK, France, Germany, Italy, and Australia from 01/01/2005 to 01/05/2016. Patients were included if their first TT regimen was recorded during this period and they had ≥12 months data pre-index (COPD diagnosis). The proportion of patients on TT before COPD diagnosis was also determined. Treatment pathways and time to TT initiation following index were evaluated. Adherence to TT was estimated using proportion of days covered. Results: Overall 130,729 eligible patients were included. Mean age at diagnosis ranged from 63.4 (SD:10.4) years [pneumologist-treated in Germany] to 69.8 (9.9) years [Italy]. Time to TT ranged from median 16.9 months in Australia (IQR: 5.7 – 36.2) to 42.5 months in the UK (IQR: 13.9 -87.4). TT initiated first formed the largest treatment pathway (7.5% in UK to 17.1% in France). In meta-analyses of patients across all countries, 20.4% (95% CI: 13.8-29.1%) of patients initiated TT prior to COPD diagnosis. Estimated adherence was >80% in all countries during the time the patient was persistent with TT. Conclusions: Diverse patient pathways to TT were observed both between and within countries, many of which do not align with COPD treatment recommendations.