COPD Exacerbation Frequency and Treatment Strategy Differs by GOLD Stage

This article is part of Pulmonology Advisor‘s coverage of the American Thoracic Society International Conference, taking place in Dallas, Texas. Our staff will report on medical research related to asthma and other respiratory conditions, conducted by experts in the field. Check back regularly for more news from ATS 2019.

DALLAS — Patients with chronic obstructive pulmonary disease (COPD who have the most severe airflow obstructions according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document had more exacerbations than those with less severe obstructions, and patients with more severe COPD were more likely to be treated with both systemic corticosteroids (SCS) and antibiotics, according to research presented at the American Thoracic Society’s International Conference, held May 17-22, in Dallas, Texas.

GOLD uses exacerbation frequency to assess the severity of COPD and guide treatment, which may be a marker of event severity. In the DYNAGITO trial (ClinicalTrial.gov Identifier: NCT02296138), researchers investigated the exacerbation rate of patients treated with antibiotics, SCS, or both by patient GOLD stage at baseline. The study included patients with COPD with postbronchodilator forced expiratory volume (FEV) <60% predicted at baseline and ≥1 moderate or severe exacerbation in the prior 12 months. Patients were randomly assigned 1:1 into double-blind groups receiving tiotropium/olodaterol 5/5µg or tiotropium 5µg once daily, delivered via tiotropium inhaler for 52 weeks. The post hoc analysis classified patients as GOLD stage 1 to 4, and a negative binomial model was used to find the annualized rate of moderate to severe COPD exacerbations requiring treatment with antibiotics, SCS, or both.

Of the 7880 patients enrolled in the trial, 47 were classified as GOLD 1, 2784 as GOLD 2, 4039 as GOLD 3, and 992 as GOLD 4. A total of 3523 participants experienced a moderate or severe COPD exacerbation during the course of the trial. A similar rate of events treated with SCS or antibiotics alone was seen in both GOLD 2 and 3 patients, and these events were more frequent in GOLD 4 patients than GOLD 3 patients (antibiotics only: rate ratio [RR], 1.24; 95% CI, 1.05-1.47; P =.0107; SCS only: RR, 1.39; 95% CI, 1.10-1.77; P =.0062) and GOLD 2 patients (antibiotics only: RR, 1.23; 95% CI, 1.03-1.47; P =.0209; SCS only: RR, 1.61; 95% CI, 1.24-2.08; P =.0003). The rate of events treated with both antibiotics and SCS increased with each subsequent GOLD stage. GOLD 4 patients had a significantly higher rate of events compared with GOLD 3 patients (RR, 1.35; 95% CI, 1.19-1.53; P <.0001) and GOLD 2 patients (RR, 1.91; 95% CI, 1.66-2.20; P<.0001). GOLD 3 patients had a significantly higher rate of events treated with both antibiotics and SCS compared with GOLD 2 patients (RR, 1.42; 95% CI, 1.28-1.57; P<.0001).

Study investigators concluded, “Patients with the most severe airflow obstruction had more exacerbations than patients with less severe airflow obstruction. In particular, the rate of exacerbations treated with antibiotics and steroids increased with increasing GOLD stage, which may reflect either an increasing rate of more severe exacerbations in these patients or that physicians treat any exacerbation more aggressively in patients with more severe underlying disease.”

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Reference

Rabe KF, Anzueto A, Jenkins C, et al. The frequency of exacerbations treated with antibiotics, steroids or both differs by GOLD stage in patients with COPD in the DYNAGITO trial. Presented at: the American Thoracic Society International Conference; May 19, 2019; Dallas, TX. Abstract 2449/215.