Comorbidities and Medication Burden in Patients With Chronic Obstructive Pulmonary Disease Attending Pulmonary Rehabilitation Ben Noteboom, BSc Physiotherapy; Sue Jenkins, Grad Dip Physiotherapy, PhD; Andrew Maiorana, PhD; Nola Cecins, B App Sci Physiotherapy, MSc; Cindy Ng, Dip Physiotherapy, MSc; Kylie Hill, BSc Physiotherapy, PhD

■ PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by concomitant systemic manifestations and comorbidities such as cardiovascular disease. Little data exist on the prevalence of comorbidities and medication burden in people with COPD attending pulmonary rehabilitation (PR) programs in Australia. This study aimed to determine the prevalence of comorbidities and describe the type and number of medications reported in a sample of patients with COPD referred to PR. ■ METHODS: A retrospective audit was conducted on patients referred to PR over a 1-year period. Data were collected on patient demographics, disease severity, comorbidities, and medications by review of patient notes, physician referral, and self-reported medication use. ■ RESULTS: Data were available on 70 patients (forced expiratory volume in 1 second = 37.5 [26.0] % predicted). Ninety-six percent of patients had at least 1 comorbidity, and 29% had 5 or more. The most common comorbidities were associated with cardiovascular disease (64% of patients). Almost half of the sample was overweight or obese (49%). Prescription medication use was high, with 57% using between 4 and 7 medications, and 29% using 8 or more. ■ CONCLUSIONS: Patients with COPD attending PR in Australia have high rates of comorbidity. The number of medications prescribed for these individuals is similar to that seen in other chronic disease states such as chronic heart failure. Pulmonary rehabilitation presents opportunities for clinicians to educate patients on self-management strategies for multiple comorbidities, review medication usage, and discuss strategies aimed at optimizing adherence with medication regimes.



chronic obstructive pulmonary disease comorbidity polypharmacy pulmonary rehabilitation Author Affiliations: School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia (Mr Noteboom, Drs Jenkins, Maiorana, and Hill, and Ms Ng); Physiotherapy Department, Royal Perth Hospital, Perth, Western Australia, Australia (Mr Noteboom); Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Western Australia, Australia (Mr Noteboom, Drs Jenkins and Hill, and Mss Cecins and Ng); Physiotherapy Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia (Dr Jenkins and Ms Cecins); Cardiac Transplant and Advanced Heart Failure Service, Royal Perth Hospital,

Perth, Western Australia, Australia (Dr Maiorana); and Community Physiotherapy Services, North Metropolitan Area Health Service, Perth, Western Australia, Australia (Ms Cecins). None of the authors have any conflicts of interest to declare. Correspondence: Kylie Hill, BSc Physiotherapy, PhD, School of Physiotherapy, Curtin University, GPO Box U1987, Perth, Western Australia, Australia 6845 ([email protected]). DOI: 10.1097/HCR.0000000000000036

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Chronic obstructive pulmonary disease (COPD) is a common and costly condition that is predicted to be the third leading cause of death and fifth leading cause of disability worldwide by 2020.1 Although characterized by persistent expiratory airflow obstruction, comorbidities contribute importantly to the functional limitation of people with this condition. In addition, there are robust data showing that comorbidities such as cardiovascular disease (CVD) and lung cancer impact on the survival of people with COPD.2 Multicomorbidity in people with COPD contributes substantially to the disease burden. In a prospective, multicenter European study of 316 patients with COPD, 62% reported having at least 1 comorbidity, with those most commonly reported being systemic hypertension, CVD, arthritis, mood disorders, gastrointestinal conditions, pulmonary hypertension, and diabetes.3 Furthermore, there is increasing recognition of the prevalence of obesity among people with COPD, with recent data suggesting that approximately 22% of people with COPD are obese.4 The prevalence of comorbidities in people with COPD is likely to be influenced by common etiological factors, such as prolonged exposure to cigarette smoke, chronic systemic inflammation, and profound physical inactivity. Data pertaining to the medication burden of treating comorbidities in COPD are scarce. This is surprising, given that poor adherence to medication regimens is associated with increased hospitalization and mortality in people with COPD and those with common comorbidities such as CVD.5,6 Factors that are likely to contribute to the poor adherence with medication in people with COPD include inadequate knowledge and perception of their condition, poor health literacy, the complexity of their medication regimen, and the presence of comorbidities.7 Given the association between poorer outcomes and medication regimen adherence, the total medication burden in this patient population is likely to be of clinical importance. Pulmonary rehabilitation (PR) is an individualized, multidisciplinary intervention comprising components of exercise training, education, and collaborative selfmanagement strategies aimed at behavioral change to improve health-related outcomes in patients with chronic respiratory disease.8 As such, participation in PR programs offers an opportunity to evaluate and manage comorbidities as well as implement strategies that may optimize adherence with complicated medication regimens. However, the medication burden among people with COPD referred to PR has not been reported.

METHODS A retrospective prevalence study was conducted at an outpatient tertiary hospital-based PR program in Perth, Western Australia. Individuals were eligible for inclusion if they had a physician-based diagnosis of COPD, were deemed suitable for PR (by a specialist PR physiotherapist), and had completed their baseline assessment before commencing the PR program between January 1 and December 31, 2010.

Data Collection An experienced physiotherapist reviewed the physiotherapy patient notes (including information recorded during the baseline assessment) of those who met the study criteria. A standardized form was used to record data regarding (i) demographic and anthropometric variables, (ii) measures of spirometry, (iii) 6-minute walk distance, (iv) modified Medical Research Council dyspnea grade, (v) comorbidities, and (vi) medication use. All patients are mailed a self-complete form on which to record medications before their initial assessment or requested to provide their own lists (eg, from physician or pharmacy records). Patients were classified as having a comorbidity if (i) it was documented by the physician on the patient referral to PR, (ii) it was recorded by the physiotherapist in the patient notes following the initial assessment for PR, or (iii) patients were taking a prescription medication that could be directly associated with a specific comorbidity.

RESULTS Data were available from 70 patients with COPD (Table 1). The majority of patients (97%) had moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grades II to IV). Most patients (84%) experienced moderate functional limitation due to breathlessness in daily life (modified Medical Research Council dyspnea grade 2 or 3). Almost half (49%) of the patients were overweight or obese, and approximately a quarter (26%) of them were underweight.

Prevalence of Comorbidities Ninety-six percent of patients had at least 1 comorbidity (median 3, range 0-9), with almost one-third (n = 20, 29%) having 5 or more comorbidities. The most common comorbidity was “cardiovascular syndrome” and associated risk factors (n = 44, 64%), which included systemic hypertension, dyslipidemia, ischemic heart disease, chronic heart failure, vasculopathies,

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Gender, M:F


Age, y

69.9 ± 9.3

anxiety, and/or patients using mood modifying agents such as selective serotonin reuptake inhibitors, (iv) cancer (n = 10, 14%), and (v) diabetes mellitus (n = 8, 11%).

T a b l e 1 • Patient Characteristics (n = 70)a


0.89 [0.62]

Medication Burden


2.49 [1.19]


0.42 [0.17]

FEV1% pred

38 [26]

Table 2 summarizes the proportion of patients using different types of medications. The median number of prescription medications used was 6 (range 2-14).

FVC% pred

72 [21]b

BMI, kg·m−2

24.8 ± 5.0c

6MWD, m

353 ± 121c

Medication by Type/Class

6MWD% pred

58 ± 17d

Respiratory medication

GOLD grades, n (%) Grade 1

2 (3)

Grade 2

20 (29)

Grade 3

29 (41)

Grade 4

19 (27)

mMRC dyspnea grade, n (%)e

T a b l e 2 • Medication Use Proportion Using (%) 99



Combined LABA and ICS








Oxygen therapy


Cardiovascular medication (prescription only)



6 (11)


21 (38)




25 (46)

ACE inhibitor



3 (5)



Calcium channel blocker


Comorbidities and medication burden in patients with chronic obstructive pulmonary disease attending pulmonary rehabilitation.

Chronic obstructive pulmonary disease (COPD) is characterized by concomitant systemic manifestations and comorbidities such as cardiovascular disease...
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