Evaluation of Pharmacist-Driven Inhaled Corticosteroid De-escalation in Veterans

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend inhaled corticosteroids (ICSs) for patients with elevated eosinophil counts who experience chronic obstructive pulmonary disease (COPD) exacerbations while receiving non-ICS inhaler therapy. The guidelines also encourage de-escalation based on eosinophil counts and adverse events (AEs) associated with ICS use. This quality improvement project sought to determine the impact of pharmacist-driven de-escalation on ICS use in veterans with COPD.

Candidates for ICS de-escalation were identified using a population health database and screened for inclusion. A Computerized Patient Record System progress note was entered recommending ICS de-escalation, initiation of non-ICS alternatives, and/or referral to a pharmacist for management. Patient charts were reviewed at baseline, 3 months, and 6 months after progress note entry. The primary endpoint was the number of patients with de-escalated ICSs. Secondary endpoints included the number of COPD exacerbations and the number of documented ICS AEs.

One hundred and six patients received an ICS de-escalation recommendation. At 3 months, 50 patients (47.2%) had their ICS therapy de-escalated; at 6 months, 62 patients (58.5%) de-escalated. More cases of pneumonia occurred in patients using an ICS than in patients not using an ICS. A similar number of COPD exacerbations occurred in patients using an ICS vs those who had been de-escalated.

The results of this study suggest that pharmacist-driven ICS de-escalation may be an effective way to reduce ICS use in veterans. Controlled studies are needed to evaluate the efficacy and safety of pharmacist-driven ICS de-escalation.