Prescribing of inhaled corticosteroids-containing and non-inhaled corticosteroids therapy in patients with chronic obstructive pulmonary disease at a Malaysian tertiary care center

Lukman Nul Hakim Md Khairi Mohd Shahezwan Abd Wahab Norkasihan Ibrahim Norhaya Mohd Razali Nur Wahida Zulkifli   

Open Access   

Published:  Nov 14, 2022

DOI: 10.7324/JAPS.2023.130208

Inhaled corticosteroids (ICS) are a common pharmacotherapy option for chronic obstructive pulmonary disease (COPD) patients. However, previous reports showed that ICS has been overprescribed. This study aimed to identify the prevalence of and factors associated with the prescribing of ICS-containing and non-ICS therapy among a sample of COPD patients at a Malaysian hospital and to examine the patterns of COPD inhaled therapy prescriptions among the patients in the years 2017–2020. The study also aimed to determine the proportion of ICS-containing therapy users that were suitable for ICS withdrawal. In total, 153 COPD patients who were using an ICS-containing or a non-ICS therapy within the study period (2017–2020) were included. Most patients were male (91.5%) and Malays (96.1%). Overall, 45.1% of the patients had been prescribed an ICS-containing therapy. A history of moderate exacerbations, presence of concurrent asthma, and eosinophilia were significantly associated with ICS-containing therapy prescribing. A decreasing trend in ICS-containing therapy prescribing from 2017 to 2020 was observed. During the most recent clinic follow-up, 77 patients were ICS users and 26% of them could benefit from ICS withdrawal. Measures to improve ICS-containing therapy prescribing and de-prescribing are warranted.

Keyword:     Chronic obstructive pulmonary disease COPD inhaled therapy inhaled corticosteroids Malaysia inhaled corticosteroids withdrawal


Md Khairi LNH, Wahab MSA, Ibrahim N, Mohd Razali N, Zulkifli NW. Prescribing of inhaled corticosteroids containing and non-inhaled corticosteroids therapy in patients with chronic obstructive pulmonary disease at a Malaysian tertiary care center. J Appl Pharm Sci, 2022.

Copyright: © The Author(s). This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Sin DD, Tu JV. Inhaled corticosteroids and the risk of mortality and readmission in elderly patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2001; 164(4):580-4.

Soriano JB, Vestbo J, Pride NB, Kiri V, Maden C, Maier WC. Survival in COPD patients after regular use of fluticasone propionate and salmeterol in general practice. Eur Respir J, 2002; 20(4):819-25.

Suissa S, Coulombe J, Ernst P. Discontinuation of inhaled corticosteroids in COPD and the Risk Reduction of Pneumonia. Chest, 2015; 148(5):1177-83.

Tsiligianni I, Kampouraki M, Ierodiakonou D, Poulonirakis I, Papadokostakis P. COPD patients' characteristics, usual care, and adherence to guidelines: the Greek UNLOCK study. Int J Chron Obstruct Pulmon Dis, 2019; 14:547-56.

Vestbo J, Vogelmeier C, Small M, Higgins V. Understanding the GOLD 2011 strategy as applied to a real-world COPD population. Respir Med, 2014; 108(5):72936.

Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Chen R, Decramer M, Fabbri LM, Frith P. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. Am J Respir Crit Care Med, 2017; 195(5):557-82.

World Health Organization. Introduction to drug utilization research [ONLINE], 2003. Available via handle/10665/42627 (Accessed 08 May 2022).

World Health Organization. The global burden of disease: 2004 update [ONLINE], 2008. Available via handle/10665/43942 (Accessed 08 May 2022).

World Health Organization. The top 10 causes of death [ONLINE], 2020. Available via (Accessed 08 May 2022).

Yang IA, Clarke MS, Sim EH, Fong KM. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2012; 7:CD002991.

Agusti A, Fabbri LM, Singh D, Vestbo J, Celli B, Franssen FME, Rabe KF, Papi A. Inhaled corticosteroids in COPD: friend or foe? Eur Respir J, 2018; 52(6).

Bafadhel M, Peterson S, De Blas MA, Calverley PM, Rennard SI, Richter K, Fageras M. Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials. Lancet Respir Med, 2018; 6(2):117- 26.

Bogart M, Stanford RH, Reinsch T, Hull M, Buikema A, Hulbert E. Clinical characteristics and medication patterns in patients with COPD prior to initiation of triple therapy with ICS/LAMA/LABA: a retrospective study. Respir Med, 2018; 142:73-80.

Burgel PR, Deslée G, Jebrak G, Brinchault G, Caillaud D, Chanez P, Escamilla R, Nesme-Meyer P, Paillasseur JL, Perez T, Roche N. Real-life use of inhaled corticosteroids in COPD patients versus the GOLD proposals: a paradigm shift in GOLD 2011? Eur Respir J, 2014; 43(4):1201-3.

Calverley PMA, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, Yates JC, Vestbo J, investigators T. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med, 2007; 356(8):775-89.

Chalmers JD, Laska IF, Franssen FME, Janssens W, Pavord I, Rigau D, McDonnell MJ, Roche N, Sin DD, Stolz D, Suissa S, Wedzicha J, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD: a European respiratory society guideline. Eur Respir J, 2020; 55(6).

Chalmers JD, Tebboth A, Gayle A, Ternouth A, Ramscar N. Determinants of initial inhaled corticosteroid use in patients with GOLD A/B COPD: a retrospective study of UK general practice. NPJ Prim Care Respir Med, 2017; 27(1):1-8.

Crim C, Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, Willits LR, Yates JC, Vestbo J. Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or in combination: TORCH study results. Eur Respir J, 2009; 34(3):641-7.

Drivenes E, Ostrem A, Melbye H. Predictors of ICS/LABA prescribing in COPD patients: a study from general practice. BMC Fam Pract, 2014; 15(1):42.

Gupta N, Malhotra N, Ish P. GOLD 2021 guidelines for COPD- what's new and why. Adv Respir Med, 2021; 89(3):344-6.

Halpin DMG, Criner GJ, Papi A, Singh D, Anzueto A, Martinez FJ, Agusti AA, Vogelmeier CF. Global initiative for the diagnosis, management, and prevention of chronic obstructive lung disease. The 2020 GOLD science committee report on COVID-19 and chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2021; 203(1):24-36.

Izquierdo JL, Martin A, de Lucas P, Rodriguez-Gonzalez-Moro JM, Almonacid C, Paravisini A. Misdiagnosis of patients receiving inhaled therapies in primary care. Int J Chron Obstruct Pulmon Dis, 2010; 5:241-9.

Lee SH, Lee JH, Yoon HI, Park HY, Kim TH, Yoo KH, Oh YM, Jung KS, Lee SD, Lee SW. Change in inhaled corticosteroid treatment and COPD exacerbations: an analysis of real-world data from the KOLD/ KOCOSS cohorts. Respir Res, 2019; 20(1):62.

Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, Day NC, Dransfield MT, Halpin DMG, Han MK, Jones CE, Kilbride S, Lange P, Lomas DA, Martinez FJ, Singh D, Tabberer M, Wise RA, Pascoe SJ, Investigators I. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med, 2018; 378(18):1671-80.

Lung Health Study Research Group, Wise R, Connett J, Weinmann G, Scanlon P, Skeans M. Effect of inhaled triamcinolone on the decline in pulmonary function in chronic obstructive pulmonary disease. N Engl J Med, 2000; 343(26):1902-9.

Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz H, Tetzlaff K, Towse L, Finnigan H, Dahl R, Decramer M, Chanez P, Wouters EF, Calverley PM, Investigators W. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med, 2014; 371(14):1285-94.

Maltais F, Bjermer L, Kerwin EM, Jones PW, Watkins ML, Tombs L, Naya IP, Boucot IH, Lipson DA, Compton C. Efficacy of umeclidinium/vilanterol versus umeclidinium and salmeterol monotherapies in symptomatic patients with COPD not receiving inhaled corticosteroids: the EMAX randomised trial. Respir Res, 2019; 20(1):1-15.

Melzer A, Bolduc J, Chezik L, Kunisaki K, Hegland A. Pharmacist driven de-escalation of inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease [ONLINE], 2020. Available via (Accessed 08 May 2022).

Ministry of Health Malaysia. Clinical practice guidelines: management of chronic obstructive pulmonary disease [ONLINE], 2017. Available via copd.pdf (Accessed 08 May 2022).

Miravitlles M, Cosio BG, Arnedillo A, Calle M, Alcazar- Navarrete B, Gonzalez C, Esteban C, Trigueros JA, Rodriguez Gonzalez- Moro JM, Quintano Jimenez JA, Baloira A. A proposal for the withdrawal of inhaled corticosteroids in the clinical practice of chronic obstructive pulmonary disease. Respir Res, 2017; 18(1):198.

Pavord ID, Lettis S, Locantore N, Pascoe S, Jones PW, Wedzicha JA, Barnes NC. Blood eosinophils and inhaled corticosteroid/long-acting beta-2 agonist efficacy in COPD. Thorax, 2016; 71(2):118-25.

Pharmaceutical Services Program. Respiratory medication therapy adherence clinic protocol: asthma/COPD (adult & paediatric) [ONLINE]. 2nd edition, 2015. Available via respiratory-medication-therapy-adherence-clinic-protocol-asthma-copd-adult-paediatric-2nd-edition.html (Accessed 08 May 2022).

Rani NS, Wahab MSA, Zulkifly HH, Mohamad SH. Factors associated with disease progression among hormone receptor-positive breast cancer patients treated with endocrine therapy: A 5-year cross-sectional, retrospective follow-up study. J Appl Pharm Sci, 2021; 11(01):72-7.

Roman-Rodriguez M, van Boven JF, Vargas F, Contreras CC, Lamelas G, Gestoso S, Gongora M, Corredor M, Esteva M. Factors associated with inhaled corticosteroids prescription in primary care patients with COPD: a cross-sectional study in the Balearic Islands (Spain). Eur J Gen Pract, 2016; 22(4):232-9.

Rossi A, van der Molen T, del Olmo R, Papi A, Wehbe L, Quinn M, Lu C, Young D, Cameron R, Bucchioni E, Altman P. INSTEAD: a randomised switch trial of indacaterol versus salmeterol/fluticasone in moderate COPD. Eur Respir J, 2014; 44(6):1548-56.

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