Implementation of a Targeted Inhaled Corticosteroid De-Escalation Process in Patients with Chronic Obstructive Pulmonary Disease in the Primary Care Setting

Purpose: To evaluate the feasibility and success of a pharmacist-led, targeted inhaled corticosteroid (ICS) de-escalation process in patients with chronic obstructive pulmonary disease (COPD) where the risks of ICS therapy outweigh the potential benefits. Methods: A population health data management tool was leveraged to identify patients who may qualify for ICS de-escalation. Primary care pharmacists clinically reviewed and subsequently contacted patients who were determined to be appropriate candidates. After discussion on the risks and benefits of ICS therapy, a stepwise algorithm was utilized to assist with ICS de-escalation and optimization of bronchodilator therapy. Outcomes analyzed include the proportion of patients for whom ICS was de-escalated, patient acceptability of the intervention, time taken to complete the intervention, barriers to implementation, and the number of additional interventions made by pharmacists. Results: Of the 126 patients originally identified as potential candidates, 58 (46.0%) were deemed appropriate to proceed with ICS de-escalation and successfully contacted by a pharmacist. Of these patients, 49 (84.5%) were agreeable and ultimately 42 were successfully de-escalated with 37 patients maintained off ICS. The average time required for an encounter was 15.8 minutes. Conclusion: There is utility in a pharmacist-driven, targeted ICS de-escalation process to facilitate meeting guideline-directed medication therapy goals in patients with COPD, granted the availability of efficient tools to assist in identifying patients that qualify. Such a targeted approach increases pharmacist involvement in medication management of COPD and can expand the primary care pharmacy practice.