Disease Stability in COPD: A Longitudinal Analysis of the Swedish National Airway Register

Authors: L Vanfleteren, et al.

This retrospective longitudinal cohort study evaluated disease stability in patients with chronic obstructive pulmonary disease (COPD) using data from the Swedish National Airway Register between 2013 and 2024. The analysis included 7,648 patients with repeated measurements of forced expiratory volume in 1 second (FEV₁), COPD Assessment Test (CAT) scores, and exacerbation history. Disease stability was assessed over 6- and 12-month periods using three criteria: no exacerbations, CAT score change <2 points, and absolute FEV₁ change <0.10 L. Three-component stability required meeting all criteria simultaneously. Mean patient age was 69 ± 9 years, 57% were female, and mean predicted FEV₁ was 56 ± 18%. At 6 months, only 11% of patients achieved three-component stability, decreasing to 8% at 12 months. Over 6 months, 73% of patients remained exacerbation-free, 48% of patients had stable symptoms, and 26% met the FEV₁ stability criterion. Similar findings were observed at 12 months, with lung function identified as the least stable component. 

Overall, multidomain disease stability in COPD was uncommon and often temporary, despite many patients remaining free from exacerbations.

Clinical and Social Drivers of Triple Therapy Initiation Amongst Patients with COPD Exacerbations: Results from the US DUALITY Disparities Study

Author: C Chima-Melton, et al.

This retrospective observational study evaluated initiation of inhaled triple therapy among patients with chronic obstructive pulmonary disease (COPD) following exacerbations and examined differences based on clinical and social factors. The analysis included 338,947 patients aged ≥40 years identified from Medicare Fee-for-Service and Inovalon MORE2 Registry claims databases. Eligible patients had at least one severe or two moderate COPD exacerbations between 2022 and 2023. Overall, only 23,445 patients (6.9%) initiated triple therapy within 12 months after an exacerbation. Significant differences in triple therapy initiation were observed according to age, sex, race/ethnicity, payer type, and geographic region (all p<0.0001). Triple therapy initiation was more common among patients aged 50–64 years (7.9%) compared with those aged ≥80 years (5.2%). Patients with COPD symptoms were more likely to initiate triple therapy, including those with cough (8.8%), dyspnea (9.5%), sputum or mucus production (10.7%), and wheezing (12.7%). Patients with pneumonia or tobacco dependence also had higher initiation rates.

Overall, most patients with COPD exacerbations did not initiate triple therapy despite GOLD recommendations, highlighting potential gaps in implementation and healthcare disparities.

Treatment Patterns for Chronic Obstructive Pulmonary Disease (COPD) Maintenance Therapy among Incident and Prevalent Patients in the United States (US): Findings from the DUALITY Patient Journey Study

Authors: T Siddharthan, et al.

This retrospective real-world study evaluated inhaled maintenance therapy use among patients with chronic obstructive pulmonary disease (COPD) in the United States using Komodo Research Data from 2016 to 2024. The analysis included 1,421,278 COPD patients aged ≥40 years, of whom 153,390 were incident cases and 1,267,888 were prevalent cases. Patients were classified as incident if their first observed COPD diagnosis occurred on or after January 1, 2022 (index date: diagnosis date), and as prevalent if they had a COPD diagnosis before 2022 (index date: January 1, 2022). Mean follow-up duration was 16.6 months for incident patients and 24.7 months for prevalent patients. During follow-up, oral corticosteroids were commonly used in 43.6% of incident and 53.7% of prevalent patients, while antibiotics were used in 67.1% and 75.6%, respectively. Oxygen therapy and non-invasive ventilation were less common. Only 33.0% of incident patients and 51.2% of prevalent patients received inhaled maintenance therapy. Dual therapy was the most commonly prescribed regimen, used in 20.2% of incident and 32.5% of prevalent patients, primarily driven by inhaled corticosteroid/long-acting beta agonist (ICS/LABA) combinations. Triple therapy use was limited, occurring in 12.5% of incident and 22.5% of prevalent patients. Among patients initiating maintenance therapy, pulmonologists accounted for 18.6% of prescribing physicians and prescribed triple therapy more frequently than overall prescribers (33.4% vs 26.4%).

Across lines of therapy, monotherapy use remained stable at approximately 20%, while triple therapy use increased to around 40% by the third line of therapy. Treatment discontinuation was the most common reason for therapy change, occurring in approximately 30–50% of patients.

Overall, inhaled maintenance therapy and triple therapy use remained limited in real-world COPD management, while frequent oral corticosteroid and antibiotic use suggested ongoing exacerbation burden and possible undertreatment.

From Flare to First Dose: Evaluating Treatment Delays for COPD Exacerbations

Authors: L Bolden, et al.

This epidemiological study evaluated delays in treatment initiation for chronic obstructive pulmonary disease (COPD) exacerbations after symptom reporting using UCHealth electronic medical record data from 2023 to 2025. The analysis included 8,128 patients aged ≥40 years treated with systemic corticosteroids for COPD exacerbations. Mean patient age was 70.3 years, and 56.7% were female. The primary outcome was treatment-response-time, defined as the interval between symptom reporting and corticosteroid treatment. Overall mean response-time was 3.6 ± 4.3 days. Approximately two-thirds of patients (63.6%) received treatment one or more days after symptom reporting, with a mean response-time of 5.6 ± 4.3 days and a maximum delay of 15 days. Treatment response-times varied significantly by care setting. Patients treated at home without an in-person visit had the shortest response-time at 2.1 days. Mean response-times were 3.4 days for office visits, 4.0 days for emergency department visits, and 4.5 days for hospitalized patients. Compared with home treatment, response-times were significantly longer in office, emergency department, and hospital settings (p<0.001 for all comparisons).

Overall, treatment delays following COPD exacerbation symptom reporting were common, and response-times differed according to treatment setting.

Blood Eosinophil Dynamics in COPD: Impact of Exacerbations and Corticosteroid Use in a Nationwide Study

Authors: M Borg, et al.

This nationwide Danish cohort study evaluated the long-term variability of blood eosinophil counts in patients with chronic obstructive pulmonary disease (COPD). The analysis included 63,517 COPD patients with at least four eosinophil measurements over a median follow-up of 3.4 years. Blood eosinophil levels were categorized as <0.15, 0.15–0.29, and ≥0.30 ×10⁹/L. Overall, 74% of patients changed eosinophil categories at least once during follow-up, while only 26% maintained stable eosinophil levels throughout the study period. A high baseline eosinophil count (≥0.30 ×10⁹/L) was associated with greater stability (odds ratio [OR] 1.70; 95% confidence interval [CI] 1.63–1.77). Although severe exacerbations and treatment with oral corticosteroids or antibiotics were associated with eosinophil shifts, more than 80% of eosinophil changes occurred without these clinical events. Among patients with unstable eosinophil counts, 39.7% changed category once, 43.2% changed twice, and 17.1% changed categories three times during follow-up.

Overall, blood eosinophil counts showed substantial long-term variability in COPD patients, suggesting that single eosinophil measurements may be insufficient for guiding treatment decision

Clinical Outcomes and Characteristics of Patients with Chronic Obstructive Pulmonary Disease (COPD) Frequently Exacerbating while on Triple Therapy: Insights from the SIRIUS II - US Study

Authors: M Pollack, et al.

This retrospective cohort study compared outcomes between frequent and infrequent exacerbators with chronic obstructive pulmonary disease (COPD) receiving inhaled triple therapy (TT) in real-world clinical practice in the United States. The analysis included 82,478 patients aged ≥40 years from the IQVIA PharMetrics claims database between 2021 and 2024. Frequent exacerbators (FE) were defined as patients experiencing at least one severe or two moderate exacerbations within 12 months while on triple therapy. These patients were compared with matched infrequent exacerbators (IE, patients with similar levels of TT exposure who had not yet experienced frequent exacerbations). Mean age was similar between groups (64.2 vs 64.6 years), although a greater proportion of FE patients were female (61.0% vs 56.4%). Compared with IE patients, FE patients had higher baseline rates of acute respiratory failure (43.5% vs 27.3%), anxiety (40.2% vs 35.0%), chest pain (42.3% vs 33.1%), cough (47.7% vs 35.6%), and dyspnea (71.8% vs 58.5%). During follow-up, exacerbation incidence rates were 44% higher in FE patients compared with IE patients (112.9 vs 78.3 events per 100 patient-years). Cardiopulmonary event rates were also higher in FE patients (22.1 vs 13.2 events per 100 patient-years), along with mortality rates (5.1 vs 4.1 events per 100 patient-years). Within the first year of follow-up, cumulative incidence of exacerbations was 64.9% in FE patients compared with 51.6% in IE patients. Cardiopulmonary events occurred in 22.1% and 13.3% of patients, respectively. Similar findings were observed in analyses restricted to patients with COPD only.

Overall, COPD patients who continued to experience frequent exacerbations despite triple therapy represented a high-risk subgroup with greater symptom burden, more cardiopulmonary complications, and higher mortality.

Clinical Factors Associated with Disease Progression in COPD Patients with Frequent Exacerbations: A Preliminary Analysis of a National Cohort Study

Authors: K Yang, et al.

This analysis from the Quality Improvement Program evaluated clinical factors associated with disease progression in chronic obstructive pulmonary disease (COPD) patients with frequent exacerbations in China. The study included 989 COPD patients from 40 hospitals between 2023 and 2025. Disease progression within 48 weeks was defined as experiencing a moderate or severe exacerbation, a decline in trough forced expiratory volume in 1 second (FEV₁) of at least 100 mL, or an increase in COPD Assessment Test (CAT) score of at least 2 units. During follow-up, 35.9% of patients experienced moderate or severe exacerbations, 31.3% had a decline in trough FEV₁ of at least 100 mL, and 14.6% had a CAT score increase of at least 2 units. Factors associated with exacerbations during the follow-up period included use of antitussive or mucolytic therapy at visit 1 (p<0.001), baseline use of long-acting muscarinic antagonist (LAMA) (p=0.002), inhaled corticosteroid plus long-acting beta agonist (ICS+LABA) (p=0.002), long-acting beta agonist plus long-acting muscarinic antagonist (LABA+LAMA) (p=0.044), methylxanthine use (p=0.044), prior severe exacerbations (p=0.006), and baseline trough FEV₁ (p<0.001). Baseline trough FEV₁ (p<0.001), previous severe exacerbations (p=0.024), and older age (p=0.038) were associated with decline in lung function. Factors associated with worsening CAT scores included antitussive or mucolytic use (p=0.032), previous severe exacerbations (p=0.025), baseline CAT score (p<0.001), baseline trough FEV₁ (p=0.002), and inhaled triple therapy (ICS+LABA+LAMA) (p=0.002) or LABA+LAMA use at visit 1 (p=0.007).

Regular use of LABA+LAMA or ICS+LABA+LAMA was associated with less worsening in CAT scores.

Patient Preferences for Triple Therapy Inhalers in Chronic Obstructive Pulmonary Disease: Findings from the US Pneumos Discrete Choice Experiment

Authors: S Miller, et al.

This web-based discrete choice experiment evaluated treatment preferences among patients with moderate to severe chronic obstructive pulmonary disease (COPD). The study included 178 patients aged ≥40 years with COPD Assessment Test (CAT) scores ≥10 and no severe exacerbations in the previous year. Participants also completed the COPD and Asthma Sleep Impact Scale (CASIS) questionnaire. The cohort had a median age of 50 years, and 40% were female. Most patients (93%) reported severe sleep disruption related to COPD during the previous week. Mean CASIS score was 50.9, while mean CAT score was 28.3. Overall, 56% of patients reported high COPD impact and 34% reported very high impact. Latent class analysis identified three patient preference groups. The largest group (52%) consisted mainly of patients with very high COPD impact, who valued improvement in nighttime symptoms most highly (relative attribute importance [RAI] 26.7%). The second group (28%) included older patients and more frequent rescue medication users. These patients prioritized reductions in mortality risk (RAI 26.2%), exacerbations (RAI 24.3%), and cardiovascular event risk (RAI 24.0%), followed by improvement in nighttime symptoms (RAI 14%). The third group (20%) mainly included younger male patients with lower COPD impact. This group prioritized treatment convenience, including dosing schedule (RAI 33.8%) and number of inhaler devices (RAI 28.8%).

Overall, reduction of nighttime symptoms was the most important treatment attribute for most COPD patients in this study.

Real-world Effectiveness of Budesonide/Glycopyrrolate/Formoterol Fumarate on COPD Exacerbations and Healthcare Costs by Eosinophil Level: Results from the U.S. ARCTOS Study

Authors: S Sethi, et al.

This retrospective real-world study evaluated the impact of budesonide/glycopyrrolate/formoterol fumarate (BGF) triple therapy on chronic obstructive pulmonary disease (COPD) exacerbations, healthcare resource utilization (HCRU), and costs across different blood eosinophil levels. The analysis included 393 COPD patients from Medicare Fee-for-Service and Inovalon MORE2 Registry claims databases between 2021 and 2024. All patients had prior exacerbations and available blood eosinophil data. Mean patient age was 68.7 years, 64.6% were female, and 77.9% were White. Blood eosinophil groups included <100 cells/µL (17.8%), 100–<300 cells/µL (46.8%), and ≥300 cells/µL (35.4%). Among patients with eosinophil counts ≥100 cells/µL, annual rates of total, moderate, and severe COPD exacerbations decreased by 28.7%, 27.7%, and 40.0%, respectively, after BGF initiation. Patients with eosinophil counts ≥300 cells/µL experienced a 50.0% reduction in severe exacerbations. Mean severe exacerbation-related hospital costs decreased by 39.2% among patients with eosinophil counts ≥100 cells/µL. Across eosinophil subgroups, approximately 90% of patients experienced no severe exacerbations after starting BGF therapy.

Overall, BGF treatment was associated with reductions in COPD exacerbations, healthcare utilization, and hospital-related costs across different eosinophil levels.

Association of Single- vs Multiple-inhaler Triple Therapy with Adherence and Exacerbation Risk in COPD: A Nationwide Cohort Study in Denmark

Authors: N Krogh, et al.

This Danish cohort study compared adherence and exacerbation outcomes between single-inhaler triple therapy (SITT) and multiple-inhaler triple therapy (MITT) in patients with chronic obstructive pulmonary disease (COPD). The analysis included 89,140 COPD patients, of whom 44,883 initiated triple inhaled therapy between 2016 and 2022. Among these, 14,665 received SITT and 30,218 received MITT. Baseline adherence before treatment initiation was similar between groups (83% for SITT vs 81% for MITT). After treatment initiation, adherence was consistently higher among patients receiving SITT. At 6 months, adherence was 93% with SITT versus 78% with MITT. At 12 months, adherence was 87% versus 65%, and at 24 months, 79% versus 49%, respectively. Adherence improved substantially following the switch from MITT to SITT, rising from 71% to 93%. Annual exacerbation rates were lower with SITT compared with MITT. Rates of any exacerbation were 1.05 versus 1.09 events annually (adjusted rate ratio [RR] 0.95; 95% confidence interval [CI] 0.92–0.97), while severe exacerbation rates were 0.24 versus 0.27 annually (RR 0.88; 95% CI 0.83–0.93). SITT was also associated with lower risk of first exacerbation and first severe exacerbation in competing-risk analyses.

Overall, SITT was associated with improved long-term adherence and reduced exacerbation risk compared with MITT in real-world COPD management.

Real-World Evaluation of Medication Adherence to Single-Inhaler Triple Therapy for Chronic Obstructive Pulmonary Disease: The Life Study

Authors: H Ogata, et al.

This real-world Japanese study evaluated medication adherence to two single-inhaler triple therapy (SITT) regimens in patients with chronic obstructive pulmonary disease (COPD): fluticasone furoate/umeclidinium/vilanterol (FUV) and budesonide/glycopyrronium/formoterol (BGF). The analysis included 4,077 patients aged ≥40 years with COPD who newly initiated FUV or BGF between April 2020 and March 2022. Data were obtained from the LIFE Study, a population-based cohort linking health insurance and medical assistance claims across 19 municipalities in Japan. Of the included patients, 2,373 received FUV and 1,704 received BGF. Medication adherence was assessed using the proportion of days covered (PDC), with good adherence defined as PDC ≥0.8.

The median PDC was higher in the FUV group compared with the BGF group (0.69 vs 0.45). The proportion of patients with good adherence was also greater with FUV than with BGF (42.6% vs 27.8%). After multivariable adjustment, patients receiving FUV had a significantly higher likelihood of achieving good adherence compared with those receiving BGF, with an adjusted risk ratio (RR) of 1.39 (95% confidence interval [CI], 1.28–1.51).

Overall, the study showed that FUV was associated with better adherence than BGF in routine clinical practice in Japan. However, more than half of patients in both treatment groups demonstrated poor adherence during follow-up, highlighting the need for strategies to improve long-term adherence to inhaled therapy in COPD management.

Association Between Airway Mucus Plugs on Computed Tomography and Respiratory Outcomes in Participants with COPD and with Normal Spirometry: Results from a Prospective Observational Population-based Cohort Study in China

Authors: F Wu, et al.

This prospective cohort study from China evaluated whether airway mucus plugs are associated with respiratory outcomes in individuals with chronic obstructive pulmonary disease (COPD) and those with normal spirometry. A total of 1,939 participants (847 with COPD and 1,092 with normal spirometry) underwent spirometry, chest computed tomography (CT), and follow-up assessments, with 89% completing 3-year follow-up. Mucus plugs were categorized as affecting 0, 1–2, or ≥3 lung segments. Among participants with normal spirometry, the presence of mucus plugs was associated with a higher exacerbation risk. Compared with participants without mucus plugs, the relative risk (RR) of exacerbations was 1.22 (95% confidence interval [CI], 1.01–1.48) for 1–2 mucus plugs and 1.42 (95% CI, 1.11–1.81) for ≥3 mucus plugs. Participants with normal spirometry and ≥3 mucus plugs also had a higher risk of developing spirometry-defined COPD (18.2% vs 7.6%; RR 1.71; 95% CI, 1.05–2.78) and showed faster decline in forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC). Among participants with COPD, including mild-to-moderate and asymptomatic COPD, mucus plugs were associated with a higher risk of moderate-to-severe exacerbations.

Overall, airway mucus plugs were associated with increased exacerbation risk and progression to spirometry-defined COPD.

ATS 2026, May15 –20, Orlando, Florida