Poor Persistence After Single-Device ICS/LABA Start in COPD Primary Care
Treatment pathways after ICS/LABA initiation in chronic obstructive pulmonary disease moved away from the idealized long-term maintenance model. In this English primary care cohort, many patients were no longer on the indexed inhaler within a year, and adherence remained low across the follow-up window. The pattern matters because inhaled corticosteroid and long-acting beta2-agonist combinations are designed to reduce symptoms and lower exacerbation risk through sustained airway anti-inflammatory and bronchodilator effects, not brief exposure followed by early discontinuation.
The study used linked data from primary care and hospital records to follow new users of single-device ICS/LABA therapy between July 2015 and December 2018. Among 13,451 new users, 5,162 had no prior maintenance therapy history and were classed as initial maintenance therapy users. The remainder had prior maintenance exposure, but the most clinically revealing findings came from those starting their first maintenance regimen, where treatment drift, resource use, and adherence were tracked over 12 months.
Discontinuation and Switching Were Common Within Months
At 3 months after treatment start, 45.6% of initial maintenance therapy users were still receiving any ICS/LABA. By 12 months, that figure had fallen to 39.4%.
Those numbers point to early attrition in a therapy class that depends on regular use to preserve benefit. In real-world COPD care, discontinuation can reflect inadequate symptom control, inhaler technique issues, treatment burden, adverse effects, access barriers, or a reassessment of whether an inhaled corticosteroid-containing regimen is the right fit for the patient’s exacerbation profile. Whatever the reason for stopping, the practical consequence is the same: the anti-inflammatory component of the regimen is removed, and the expected reduction in exacerbation risk becomes harder to achieve.
Adherence was low at every measured time point, with proportion of days covered at or above 80% ranging from 21.5% to 27.6%. Those values suggest that most patients did not maintain consistent exposure to their prescribed maintenance inhaler. For a chronic airway disease with fluctuating symptoms, this kind of underuse can quietly erode control long before the next clinic review.
Hospital Use and Costs Rose as Follow-Up Continued
Healthcare resource use did not stay flat over the year. At more than 6 to 12 months after index, 10.1% of initial maintenance therapy users had at least one outpatient visit, compared with 9.0% at 3 months. The proportion with at least one inpatient stay also increased, from 7.4% at 3 months to 12.6% later in follow-up.
Inpatient stays contributed most to total COPD-related healthcare costs. This is the cost center that usually signals clinically meaningful deterioration rather than routine outpatient management. Hospital admission in COPD often reflects exacerbation severity, frailty, comorbidity burden, or failure of outpatient treatment to contain worsening respiratory symptoms. When admissions dominate the cost profile, they also expose the gap between prescription and sustained disease control.
For the subgroup of non-triple initial maintenance therapy users, moderate-to-severe exacerbations were documented in 4.5% at 3 months and 13.7% at 12 months. The upward movement over time fits with a disease course in which unstable control accumulates after the initial prescription window closes. Inflammatory activity in COPD does not pause because a treatment has been written; if adherence erodes, so does pharmacologic protection.
Time to Triple Therapy and Time to Discontinuation Varied by Regimen
Among initial maintenance therapy users, the time to triple therapy initiation ranged from 45.9 to 50.2 months across treatments, while the time to discontinuation of the indexed medication ranged from 2.3 to 2.8 months. Those two timeframes tell different stories. One reflects escalation along a longer disease-management pathway; the other reflects how quickly patients abandon or move away from the starting regimen in everyday practice.
The short time to discontinuation is especially striking. It suggests that, for a substantial proportion of patients, the first maintenance inhaler does not remain the anchor of treatment for long. In a disease where inhaler selection, device usability, and adherence are tightly linked to outcomes, early discontinuation can mean the patient never receives the intended maintenance effect long enough to judge it fairly.
Similar Patterns Across Indexed Therapies
Results were broadly similar across the indexed ICS/LABA therapies evaluated, including budesonide/formoterol, beclomethasone dipropionate/formoterol, and other ICS/LABA combinations. In other words, the problem was not confined to one product choice. The real-world challenge appeared to be the treatment pathway itself: people starting ICS/LABA were frequently not staying on it, and those gaps were mirrored by ongoing exacerbations, inpatient use, and cost burden.
The cohort therefore speaks to a familiar problem in COPD management. A treatment can be evidence-based in trials and still perform poorly when prescribed into routine primary care if initiation is not matched to patient phenotype, inhaler education, and follow-up. COPD severity, exacerbation history, eosinophilic inflammation, inhaler technique, and persistence all influence whether a patient benefits from an ICS-containing regimen or drifts toward repeated switching and rescue care.
These findings support closer review of how initial maintenance therapy is selected and monitored in England. The data do not argue against ICS/LABA as a class, but they do show that prescription alone is not enough. Low adherence, early discontinuation, and rising inpatient use together point to a care process that may need earlier reassessment, better device support, and more deliberate alignment between treatment choice and the patient’s exacerbation risk profile.