COPD is Treated Differently Across Europe – What Could Be the Reasons for This Variability?

“GOLD Countries” vs. “Phenotype Countries”, National Guidelines vs. GOLD Recommendations

“The healthcare systems in Europe differ. The proportion of smokers in the population varies, and COPD patients are sometimes under the care of general practitioners and sometimes pulmonologists. For instance, there is a significant difference in smoking prevalence between the USA and Russia, with Czechs falling somewhere in the middle along with Serbs and Hungarians. There are countries where almost exclusively men smoke and women do not, and countries where it's the other way around. Could this be related to the types of guidelines used in each country?” the lecturer rhetorically asked at the beginning of his presentation.

Finding the answer, however, is fairly complex. European nations can be divided by their approach to the use of mucolytics in COPD treatment and by whether they prefer their own national guidelines or the current recommendations issued by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Even this does not fully clarify the reasons for differences in mucoactive drug prescriptions for COPD. GOLD does not oppose the administration of mucoactive drugs for COPD but lists them as an option for a certain group of patients. Examples of “GOLD countries” include Italy and Germany. Countries such as Spain, Slovenia, the Czech Republic, and Finland value their own expert recommendations and favor distinguishing various COPD phenotypes. Spanish expert guidelines clearly state that mucoactive drugs work well for certain groups of patients and have a clear role for them. In Slovenia, another “phenotype country”, seven COPD phenotypes are distinguished, but none specifically indicate that mucoactive therapy should be administered. The British and Irish also prioritize their own national guidelines. In the UK, oral mucoactive therapy is mentioned as an option but is somewhat marginal. In Ireland, there is no mention of any mucoactive medication at all.

“In our international team, we agreed that there is definitely a group of patients who benefit from mucoactive therapy,” stated Assoc. Prof. Koblížek. The Czech national guidelines also clearly describe the indications for mucoactive drugs in three COPD phenotypes – frequent exacerbations, bronchitic, and overlapping bronchiectasis and COPD.

Prescription of Mucoactive Drugs in Different European Countries

So how are mucoactive drugs actually prescribed? In Italy, one of the “GOLD countries”, there is, according to the lecturer, “a truly enormous number of products on the market, but basically the most widely prescribed drug is not the most effective one”. In Spain, one of the “phenotype countries”, acetylcysteine is the most prescribed, while erdosteine is not prescribed at all, and about a third of patients are prescribed carbocysteine. In the UK, several mucoactive drugs are available, but by far the most prescribed is carbocysteine (almost 83%), making this island state quite unique in Europe. On the other hand, Slovenia, a “phenotype country”, uses only four drugs, all variants of N-acetylcysteine. Finland, another “phenotype country”, is dedicated to erdosteine, similar to the Czech Republic.

In terms of standard units per capita, the most doses of mucoactive drugs, regardless of the product, are administered in the UK. “Less in Spain, even less in Germany, very little in Slovenia, more in Italy than in Germany, and we in the Czech Republic also give quite a lot, but not as many as in the UK. Interestingly, the UK gives out the most drugs, but the British pay only 0.364 euros per capita per year for them, whereas about 70% of the doses Czechs pay 0.9 euros per resident per year,” said the lecturer. He noted that the British National Health Service (NHS) is very conservative, but British general practitioners prescribe mucoactive drugs very actively. “The Czech Republic is second and we are champions in payments. Italy has fewer doses than we do, and they pay almost as much as us,” he added.

Conclusion

The initial question remains unanswered for now. According to Assoc. Prof. Koblížek, the significant variability mentioned is important. “It cannot be said that large countries behave differently from small ones, that there is a difference between Eastern and Western Europe, or that the reasons for differences can be found in general practitioners or pulmonologists. Essentially, no correlation was found. It can only be stated that European countries vary greatly in their prescription of mucoactive drugs,” he concluded.

Eva Srbová
MeDitorial Editorial Team