Predictors of ICS/LABA prescribing in COPD patients: a study from general practice.

BACKGROUND: A combination of inhaled corticosteroid and long-acting beta2 agonist (ICS/LABA) is used frequently to treat chronic obstructive pulmonary disease (COPD) patients. The aim of the study was to determine whether prescribing ICS/LABA to COPD patients in primary care in 2009/10 was within the GOLD guidelines and whether and to what degree patient characteristics were associated with prescription of these drugs by GPs. METHODS: This was a cross-sectional study in seven Norwegian GP practices. Patients registered with a diagnosis of asthma or COPD in the previous five years were included. RESULTS: Among the 376 patients included in the analysis, 149 patients had COPD, defined as a post-bronchodilator FEV1/FVC <0.7 and 55.6% of these patients were treated with ICS/LABA. The rate of prescribing was significantly higher in the COPD patients also diagnosed with asthma than in those with COPD as the only diagnosis, 66.7%, and 39.0%, respectively (P = 0.001). The prescribing rate in the latter subgroup would have been 18.6% if the 2007 GOLD guidelines had been followed. One or more exacerbations in the previous year was the strongest predictor of ICS/LABA prescribing in the COPD patients who were not registered with a concomitant diagnosis of asthma (OR 3.2, 95% CI 1.0-10.0) but this association was limited to the patients with severe disease (FEV1% predicted <50) (OR 13.5, 95% CI 1.8-101.1). Cardiovascular disease was associated with decreased ICS/LABA prescribing (OR 0.4, 95% CI 0.2-0.8) in the COPD group. A Kappa coefficient of 0.32 was found between the actual prescribing rate and that recommended in the 2007 GOLD guidelines. CONCLUSIONS: Overprescribing of ICS/LABA for the COPD patients was shown. Previous exacerbation was a strong predictor of ICS/LABA prescribing only in patients with severe COPD. Because of the low emphasis on previous exacerbation when prescribing for COPD patients with mild to moderate disease, the actual prescribing rate agreed more closely with the GOLD guidelines from 2007 than with those published in 2011. Cardiovascular disease was associated with decreased prescribing, indicating that GPs adjust the treatment in cases with multimorbidity.

Asthma, chronic obstructive pulmonary disease, or both? Diagnostic labeling and spirometry in primary care patients aged 40 years or more.

AIMS: To describe symptoms and lung function in patients registered with asthma or chronic obstructive pulmonary disease (COPD) in primary care and to examine how spirometry findings fit with general practitioners' (GPs) diagnoses. METHODS: Patients aged ≥40 years with a diagnosis of asthma or COPD registered in the electronic medical record during the previous 5 years were recruited at seven GP offices in Norway in 2009-2010. Registered diagnosis, spirometry results, comorbidity, and reported symptoms were compared. RESULTS: Among 376 patients, 62% were women. Based on Global Initiative for Chronic Obstructive Lung Diseases criteria, a spirometry diagnosis of COPD could be made in 68.1% of the patients with a previous COPD diagnosis and in 17.1% of those diagnosed with asthma only (P < 0.001). The κ agreement between last clinical diagnosis of COPD and COPD based on spirometry was 0.50. A restrictive spirometry pattern was found in 19.4% and more frequently in patients diagnosed with both asthma and COPD (23.9%) than in patients diagnosed with COPD only (6.8%, P = 0.003). CONCLUSION: The ability of GPs to differentiate between asthma and COPD seems to have considerably improved during the last decade, probably due to the dissemination of spirometry and guidelines for COPD diagnosis. A diagnosis of COPD that cannot be confirmed by spirometry represents a challenge in clinical practice, in particular when a restrictive pattern on spirometry is found.

Bulimia nervosa--a primary defect in the hypothalamic-pituitary-adrenal axis?

Bulimia nervosa has been associated with impaired satiety, decreased resting metabolic rate and abnormal neuroendocrine regulation. The aim of this study was to investigate the diurnal cortisol secretion and the pituitary-adrenal response to corticotropin-releasing hormone (CRH) in subjects suffering from bulimia nervosa. Eight female subjects with remitted bulimia nervosa, ages 24-56, and 8 sex- and weight-matched controls volunteered to participate. After an overnight fast they were admitted to the Clinical Research Center for 24 hour recording of plasma cortisol secretion. Blood were drawn every 2nd hour from 8 AM. After another overnight fast, the subjects performed a 120-min CRH test (100 microg i.v.), drawn for measurements of adrenocorticotropin releasing hormone (ACTH) and cortisol. Compared to the control group (CG), the diurnal cortisol secretions in the bulimic group (BG) decreased at time points 6 AM to 2 PM. In the CRH test, the ACTH response was significantly stronger in the BG than in the CG. Similar observations were found for cortisol, although not at significant levels. Remitted bulimic patients exhibit a neuroendocrine pattern of decreased HPA axis activity with a hyperreactivity to CRH. This may indicate a complex and so far poorly understood neuroendocrine dysregulation of HPA axis associated with the disease.