Abstract Introduction In 2023, chronic obstructive pulmonary disease (COPD) was the fifth leading cause of death in the United States, accounting for 141, 733 deaths. Among adults aged 45 and older, COPD incurred an estimated 24 billion in annual medical costs, with prescription drugs comprising 11. 9 billion of that total. In the same year, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated its assessment framework, replacing the ABCD tool with the ABE tool. This change was based on multiple studies demonstrating the independent clinical impact of exacerbations, regardless of symptom severity. The revised ABE tool simplifies the assessment process and enhances its intuitiveness. Given the substantial burden of COPD and the recent changes in clinical guidelines, we aimed to evaluate real-world adherence particularly focusing on the inappropriate prescription of inhaled corticosteroids (ICS). ICS use has been associated with increased risks of pneumonia, mycobacterial infections, and other complications, making guideline concordant prescribing practices critically important. Methods Data from the Global Collaborative Network of TriNetX were used to identify COPD patients aged ≥40 years who were prescribed inhaled corticosteroids (ICS) between January 2023 and October 2025, despite not meeting guideline-based criteria (i. e. , no history of exacerbations, elevated blood eosinophils, or concomitant asthma). The cohort included patients from 53 academic and 18 non-academic institutions across the United States. The primary outcome was to quantify the number of patients inappropriately prescribed ICS in academic versus non-academic settings. The secondary outcome was to compare the incidence of pneumonia between patients who received ICS and those who did not, using propensity score matching. Results Out of 115, 201 total COPD patients, 43, 244 (37. 53%) were inappropriately prescribed ICS at academic institutions. In contrast, among 26, 028 COPD patients at non-academic institutions, 7, 272 (27. 93%) received ICS inappropriately. The incidence of pneumonia was 6. 4% in the ICS cohort compared to 4. 6% in the non-ICS cohort, resulting in an absolute risk difference of 1. 822% (95% CI: 1. 5%-2. 1%). ICS use was associated with a 39. 5% higher relative risk of pneumonia (risk ratio = 1. 395, 95% CI: 1. 324-1. 470) and 42. 2% higher odds of pneumonia (odds ratio = 1. 422, 95% CI: 1. 346-1. 503). Conclusion This study underscores a significant gap between clinical guidelines and real-world prescribing practices. The inappropriate use of ICS in COPD patients is associated with an increased risk of pneumonia. These findings highlight the importance of adhering to evidence-based guidelines to optimize patient safety and outcomes. This abstract is funded by: None
Patel et al. (Fri,) studied this question.