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Anthony J Guarascio,1 Shauntá M Ray,1 Christopher K Finch,2,3 Timothy H Self21University of Tennessee College of Pharmacy, Knoxville, 2University of Tennessee College of Pharmacy, Memphis, TN, USA; 3Methodist University Hospital, Memphis, TN, USAAbstract: Chronic obstructive pulmonary disease (COPD) is the third most common cause of death in the USA. In 2010, the cost of COPD in the USA was projected to be approximately US$50 billion, which includes $20 billion in indirect costs and $30 billion in direct health care expenditures. These costs can be expected to continue to rise with this progressive disease. Costs increase with increasing severity of disease, and hospital stays account for the majority of these costs. Patients are diagnosed with COPD following a multifactorial assessment that includes spirometry, clinical presentation, symptomatology, and risk factors. Smoking cessation interventions are the most influential factor in COPD management. The primary goal of chronic COPD management is stabilization of chronic disease and prevention of acute exacerbations. Bronchodilators are the mainstay of COPD therapy. Patients with few symptoms and low exacerbation risk should be treated with a short-acting bronchodilator as needed for breathlessness. Progression of symptoms, as well as possible decline in forced expiratory volume in the first second of expiration (FEV1), warrant the use of long-acting bronchodilators. For patients with frequent exacerbations with or without consistent symptoms, inhaled corticosteroids should be considered in addition to a long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA) and may even consist of "triple therapy" with all three agents with more severe disease. Phosphodiesterase-4 inhibitors may be an option in patients with frequent exacerbations and symptoms of chronic bronchitis. In addition to a variety of novel ultra-LABAs, LAMAs and combination bronchodilator and inhaled corticosteroid (ICS) therapies, other bronchodilators with a variety of mechanisms are also being considered, to expand therapeutic options for the treatment of COPD. With more than 50 new medications in the pipeline for the treatment of COPD, optimal management will continue to evolve and grow more complex as benefits of therapy are balanced with the limitations and needs of each patient.Keywords: chronic obstructive pulmonary disease, COPD, clinical burden, economic burden

The increasing number of patients affected by chronic obstructive pulmonary disease (COPD) and associated exacerbations has led to both rising hospital admissions and significant economic impact. Evidence-based guidelines have been formulated for COPD management recommending the use of low dose, oral corticosteroid therapy in the treatment of exacerbations. However, fewer than 50% of physicians´ prescribing practices appropriately reflect the published clinical guidelines on the use of systemic corticosteroids in these patients. Objective: The purpose of this study was to evaluate the impact of a pharmacist-led educational intervention on prescribing practices and patient outcomes when using systemic corticosteroids in patients with COPD exacerbations. Methods: This retrospective case-control study included patients admitted to an inpatient family medicine service with a COPD exacerbation who received systemic corticosteroids. Two pharmacist-led educational interventions were delivered to prescribers to review current guidelines for managing COPD exacerbations with systemic corticosteroids. Patients were retrospectively identified over a three month span prior to and following the educational intervention. Data was collected via chart review to evaluate prescribing practices prior to and following the educational sessions. In addition, data was collected to evaluate the effects of an educational intervention on length of stay, adverse events, and cost of treatment. Results: A total of 23 pre-intervention patients and 18 post-intervention patients met inclusion criteria. After pharmacist-led interventions, guidelines were not more likely to be adhered to by prescribers when compared to guideline adherence in the pre-intervention patients. Because no statistically significant change in guideline adherence was observed, there was no impact on secondary outcomes. Conclusion: Pharmacist-led didactic educational interventions and guideline dissemination do not improve guideline adherence and prescribing practices with respect to systemic corticosteroids in COPD exacerbations. El creciente número de pacientes afectados por enfermedad obstructiva pulmonar crónica (EPOC) y las exacerbaciones asociadas han conducido a una elevación de los ingresos hospitalarios y un significativo impacto económico. Se crearon guías basadas en la evidencia fueron creadas para EPOC recomendando el uso de corticoides orales en baja dosis para el tratamiento de las exacerbaciones. Sin embargo, menos del 50% de los actos de prescripción reflejan lo publicado en las guías sobre el uso sistémico de corticoides en estos pacientes. Objetivo: El propósito de este estudio fue evaluar el impacto de una intervención educativa de un farmacéutico sobre la práctica de prescripción y los pacientes ambulatorios cuando se usaban corticoides sistémicos en pacientes con exacerbaciones de EPOC. Métodos: Este estudio retrospectivo caso-control incluyó pacientes ingresados en un servicio de medicina familiar con exacerbación de EPOC que recibieron corticoides sistémicos. Se desarrollaron dos realizaron intervenciones educativas de farmacéuticos a los prescriptores para revisar las guías actuales de manejo de las exacerbaciones de EPOC con corticoides sistémicos. Los pacientes fueron identificados retrospectivamente durante los tres meses previos y posteriores a la intervención. Los datos se recogieron mediante revisión del historial para evaluar las prácticas de prescripción anterior y posterior a las sesiones educativas. Además, se recogieron datos para evaluar los efectos de la intervención educativa en la duración de la estancia, eventos adversos, y coste del tratamiento. Resultados: Un total e 23 pacientes pre-intervención y 18 post-intervención cumplieron los criterios de inclusión. Después de las intervenciones del farmacéutico, las guías no eran seguidas con más probabilidad por los prescriptores cuando se comparaba el cumplimiento de guías con los pacientes pre-intervención. Como no hubo cambios estadísticamente significativos en el cumplimiento de las guías, no hubo impacto en el resultado secundario. Conclusión: Las intervenciones educativas farmacéuticas y la diseminación de guías no mejoraron el cumplimiento de las guías y las practicas de prescripción en relación al uso de corticoides sistémicos en exacerbaciones de EPOC.