Stakeholder Insight: COPD in Emerging Markets (Brazil, India, China, US) - Key differences in treatment despite standardized guidelines

Introduction

While general COPD treatment patterns are consistent across the emerging markets compared to the US, some key distinctions between countries have been identified, which impact market potential and growth opportunities. In particular, regulations in the emerging markets play a considerable role in the availability and spectrum of COPD treatments compared to the US.

Scope

*Insight into COPD in emerging markets based on a survey of 300 physicians in Brazil, India, China, and the US

*Robust and comparable epidemiology estimates of the current COPD patient population in Brazil, India, China and the US

*Overview of treatment patterns by severity, and patient segmentation by GOLD guidelines as well as by exacerbation rates, age and smoking status

*Assessment of commercial attractiveness of the emerging markets based on current COPD drug usage, regulations and intellectual property rights

Highlights

Survey respondents believe less than half of COPD patients are diagnosed. The perceived diagnosis rate was found to be the highest in the US, 45.5%, and the lowest in Brazil, 29.8%. Low diagnosis was attributed mainly to lack of patient awareness, such that with increased attention to the disease, patient potential could increase considerably.

A greater share of physician reported mild and moderate patients was found in the emerging markets versus the US. In Brazil 32.8% of patients are considered mild, over double the rate in the US (15.8%). These results suggest that, with spirometry lacking, subjectivity leads to different classifications, despite claims of GOLD criteria adherence.

Emerging markets respondents have a more fragmented choice of preferred COPD products than the US. In India, most respondents prefer products from local company Cipla. Patent laws in the emerging markets have allowed generic availability before the US, but changing regulations are expected to impact the situation in the future.

Reasons to Purchase

*Target physicians more effectively, through an understanding of prescribing behavior and influences

*Understand treatment outcomes and challenges and their relative importance to prescribing physicians

*Validate new product forecasting based on diagnosis and treatment rates, and interest in novel products

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Overview 1
Catalyst 1
Summary 1
About Datamonitor healthcare 2
About the Respiratory pharmaceutical analysis team 2
About the Epidemiology team 2
Executive Summary 3
Scope of the analysis 3
Datamonitor insight into COPD in emerging markets 3
Related reports 4
1. Introduction and Scope 6
Coverage of the Stakeholder Insight Survey 6
Epidemiology 6
Access and diagnosis 6
Patient segmentation 6
Treatment patterns and key prescribing influences 6
Treatment outcomes and compliance 7
Treatment challenges 7
Assumptions and caveats 7
2. Country Treatment Trees 8
Introduction to treatment trees 8
Brazil 9
India 11
China 13
US 15
3. Epidemiology 17
Key findings 17
Introduction 18
Disease definition, classification and diagnosis criteria 18
Epidemiology risk factors 19
Age 20
Genetics 20
Smoking 20
Male gender and smoking 21
Biomass fuels 21
Pollution 22
Industry-related exposures 22
Global variation and temporal trends 22
Underdiagnosis is common in all markets 22
Brazil 22
India 23
China 23
US 23
Trends are driven by smoking rates 23
Brazil 23
India 24
China 24
US 24
Epidemiologic calculations for COPD 24
Sources of epidemiologic data 24
Description of methods 25
Brazil 25
India 26
China 28
US 29
Age standardization 30
Results 30
Segmentation by age 31
Segmentation by gender 32
Segmentation by the urban-rural split in China and India 34
Segmentation by stage 35
Discussion 36
4. Access and Diagnosis 38
Key findings 38
Healthcare spending and burden of disease 39
Healthcare indicators by country 39
Global burden of COPD on the rise 40
Diagnosis 43
Less than half of patients are diagnosed in each country 44
Low patient awareness of COPD is a consistent barrier to diagnosis 45
Diagnosis by physician type 49
Spirometry is the number one tool for diagnosis 52
Pharmacies distribute the majority of COPD prescriptions 56
5. Patient Segmentation 59
Key findings 59
GOLD classification criteria 60
Patient breakdown by severity 60
Disease control is lower in the emerging markets 62
COPD is a disease of the elderly 67
Most COPD patients are over 40 years old 68
Brazil - age demographics 70
India - age demographics 70
China - age demographics 71
US - age demographics 72
Smoking and COPD remain clearly linked 73
Large variation in smoking rates by country 75
Smoking is more than just cigarettes 76
Novel risk factors in emerging markets 77
Growing recognition of novel risk factors 79
Occupational exposure creates excess risk of COPD 80
Biomass fuels from indoor cooking affect more people than smoking 81
Suggestive evidence of the link between passive smoking and COPD 83
Comorbidities are widespread among COPD patients 83
Comorbidities must be considered in treatment 85
6. Treatment Patterns 87
Key findings 87
COPD treatment algorithms 88
Use of guidelines 88
Comparison of guidelines 91
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 92
American Thoracic Society/European Respiratory Society (ATS/ERS) 92
National Institute for Health and Clinical Excellence/British Thoracic Society (NICE/BTS) 92
Latin American Thoracic Society (ALAT) 93
Guidelines followed to a large extent 93
Pharmacological versus non-pharmacological therapy 94
Drug classes target symptoms of COPD 98
Treatment increases with severity 98
Bronchodilators are the mainstay of symptomatic treatment 103
Corticosteroids are the only effective anti-inflammatory 105
Leukotriene antagonists not recommended for COPD treatment 107
Preferred drug treatment varies by country 107
Management of COPD 110
Management by physician type 110
Long-term management tools 112
7. Key Prescribing Influences 116
Key findings 116
Factors influencing physician decision making 117
Treatment attributes 117
Efficacy is the number one influence on prescribing behavior 119
Treatment guidelines impact prescriptions 119
Affordable medication needed to treat COPD 120
Device characteristics 121
The role of generics in treatment 124
High use of similares in Brazil impacts brand sales 125
Insufficient intellectual property rights remain in India 125
Chinese intellectual property protection conforming to international standards 126
Physician's confidence in generics 126
Comparison with asthma treatment 127
Asthma and COPD overlap 127
Asthma and COPD treatment distinction 129
8. Treatment Outcomes and Challenges 131
Key findings 131
Treatment outcomes 132
Compliance 133
Treatment challenges 135
Disease progression cannot be prevented 137
Exacerbations remain poorly managed 137
High smoking rates must be addressed 137
Future treatment combinations 138
Bibliography 141
3. Epidemiology 141
Journal papers 141
Websites 144
4. Access and Diagnosis 144
Journal papers 144
Websites 144
Datamonitor reports 145
5. Patient Segmentation 145
Journal papers 145
Websites 146
6. Treatment Patterns 147
Journal papers 147
Websites 148
7. Key Prescribing Influences 148
Journal papers 148
Websites 148
Datamonitor reports 149
8. Treatment Outcomes and Challenges 149
Journal papers 149
Websites 149
Appendix A 150
Physician research methodology 150
Physician sample breakdown 150
Contributing experts 152
Contributing authors 152
Conferences attended 153
Appendix B 154
The survey questionnaire 154
Screener 154
Introduction 155
Section 1: Access and diagnosis 155
Section 2: Patient segmentation 158
Section 3: Treatment patterns and key prescribing influences 162
Section 4: Treatment outcomes & compliance 170
Section 5: Novel therapies and treatment challenges 171
Demographics 173
Datamonitor consulting 176
Disclaimer 177
List of Tables
Table 1: Population-based studies of COPD prevalence used to estimate prevalent cases of COPD in Brazil, China, India, and the US, 2010 25
Table 2: Age-specific prevalent cases and prevalence rates of COPD in Brazil, India, China, and the US, 2010 31
Table 3: Crude and age-standardized prevalence rates (%) of COPD in Brazil, India, China, and the US, 2010 32
Table 4: Gender-specific prevalent cases and prevalence rates of COPD in Brazil, India, China, and the US , 2010 33
Table 5: Urban/rural-specific prevalent cases and prevalence rates of COPD in India and China, 2010 34
Table 6: Prevalent cases and prevalence rates of COPD in Brazil, India, China, and the US by stage, 2010 35
Table 7: Healthcare expenditure indicators in Brazil, India, China and the US, 2008 40
Table 8: Top 5 causes of mortality by country in Brazil, India, China and the US, 2004 43
Table 9: Primary reason for COPD patients being undiagnosed (%) in Brazil, India, China and the US, 2010 47
Table 10: Method of COPD diagnosis (%) in Brazil, India, China and the US, 2010 54
Table 11: Distribution channel of COPD prescriptions dispensed in Brazil, India, China and the US, 2010 57
Table 12: Diagnosed COPD patients by severity (%) in Brazil, India, China and the US, 2010 61
Table 13: Yearly COPD exacerbations by severity (%) in Brazil, India, China and the US, 2010 66
Table 14: Smoking habits in India, 2005 77
Table 15: Risk factors for the development of COPD (rating from 1-10) in Brazil, India, China and the US, 2010 79
Table 16: Physicians with COPD patients suffering comorbidities (%) in Brazil, India, China and the US, 2010 85
Table 17: Physicians' use of guidelines by for treating COPD by country (%)in Brazil, India, China and the US, 2010 90
Table 18: Pharmacological versus non-pharmacological therapy by COPD severity (%) in Brazil, India, China and the US, 2010 97
Table 19: Drug classes prescribed by COPD severity and country (%) in Brazil, India, China and the US, 2010 100
Table 20: Preferred drugs for treating COPD (%) in Brazil, India, China and the US, 2010 109
Table 21: Method of COPD tracking (%)in Brazil, India, China and the US, 2010 114
Table 22: Average number of points (out of 100) assigned to treatment attributes that influence COPD prescribing behavior in Brazil, India, China, and the US, 2010 119
Table 23: Average number of points (out of 100) assigned to device attributes in influencing COPD prescribing behavior in Brazil, India, China and the US, 2010 123
Table 24: Mean rating given to COPD challenges for the pharmaceutical industry to address (rating from 1-10) in Brazil, India, China and the US, 2010 136
Table 25: COPD survey respondent breakdown, 2010 150
Table 26: Type of hospital worked in by survey respondents, 2010 151
Table 27: Survey respondent breakdown, urban versus rural, 2010 151
Table 28: Survey respondent breakdown by gender and age, 2010 152
List of Figures
Figure 1: Brazil - COPD patient population, split by physician-estimated diagnosis, disease severity, drug-treated population and drug-class usage, 2010 9
Figure 2: Brazil - COPD patient population, segmented by severity, exacerbation rate, age, and smoking status, 2010 10
Figure 3: India - COPD patient population, split by physician-estimated diagnosis, disease severity, drug-treated population and drug-class usage, 2010 11
Figure 4: India - COPD patient population, segmented by severity, exacerbation rate, age, and smoking status, 2010 12
Figure 5: China - COPD patient population, split by physician-estimated diagnosis, disease severity, drug-treated population and drug-class usage, 2010 13
Figure 6: China - COPD patient population, segmented by severity, exacerbation rate, age, and smoking status, 2010 14
Figure 7: US - COPD patient population, split by physician-estimated diagnosis, disease severity, drug-treated population and drug-class usage, 2010 15
Figure 8: US - COPD patient population, segmented by severity, exacerbation rate, age, and smoking status, 2010 16
Figure 9: Classification of COPD as measured by airflow limitation 19
Figure 10: Age-standardized prevalence rates (%) of COPD in Brazil, India, China, and the US, 2010 32
Figure 11: Prevalent cases of COPD in Brazil, India, China, and the US by gender, 2010 33
Figure 12: Distribution of the urban-rural split and gender among prevalent cases of COPD in India and China, 2010 35
Figure 13: Distribution of GOLD stages among prevalent cases of COPD in Brazil, India, China, and the US, 2010 36
Figure 14: Global projected leading causes of death, 2008-2030 41
Figure 15: COPD patients who are diagnosed versus undiagnosed (%) in Brazil, India, China and the US, 2010 44
Figure 16: Primary reason for COPD patients being undiagnosed (%) in Brazil, India, China and the US, 2010 46
Figure 17: COPD diagnosis by physician type (%) in Brazil, India, China and the US, 2010 50
Figure 18: Method of COPD diagnosis (%) in Brazil, India, China and the US, 2010 53
Figure 19: Distribution channel of COPD prescriptions dispensed in Brazil, India, China and the US, 2010 56
Figure 20: Classification of COPD as measured by airflow limitation 60
Figure 21: Diagnosed COPD patients by severity (%) in Brazil, India, China and the US, 2010 61
Figure 22: Yearly COPD exacerbations by country in Brazil, India, China and the US, 2010 64
Figure 23: Yearly COPD exacerbations by disease severity in Brazil, India, China and the US, 2010 65
Figure 24: COPD, age, and smoking cessation 68
Figure 25: Diagnosed COPD patients by age in Brazil, India, China and the US, 2010 69
Figure 26: Brazil - population spread by age group, 2009 and 2019 70
Figure 27: India - population spread by age group, 2009 and 2019 71
Figure 28: China - population spread by age group, 2009 and 2019 72
Figure 29: US - population spread by age group, 2009 and 2019 73
Figure 30: COPD patients by smoking status in Brazil, India, China and the US, 2010 74
Figure 31: Smoking rate by gender and country (%) in Brazil, India, China and the US, 2006 75
Figure 32: Risk factors for the development of COPD (weighted mean rating from 1-10) in Brazil, China, and India, and the US, 2010 78
Figure 33: Use of biomass fuel for cooking in an Indian village - a risk factor for COPD 82
Figure 34: Physicians with COPD patients suffering comorbidities (%) in Brazil, India, China and the US, 2010 84
Figure 35: Use of guidelines for treating COPD by country (%)in Brazil, India, China and the US, 2010 89
Figure 36: Comparison of guideline recommendations for the treatment of stable COPD, 2010 91
Figure 37: Adherence to COPD guidelines (rating from 1-10) in Brazil, India, China and the US, 2010 94
Figure 38: Pharmacological versus non-pharmacological therapy by COPD severity (%) in Brazil, India, China and the US, 2010 96
Figure 39: Drug classes prescribed by COPD severity and country (%) in Brazil, India, China and the US, 2010 99
Figure 40: Use of bronchodilators by country and COPD severity (%) in Brazil, India, China and the US, 2010 104
Figure 41: Bronchodilators used in the treatment of COPD 105
Figure 42: Use of corticosteroids by country and COPD severity (%)in Brazil, India, China and the US, 2010 106
Figure 43: Preferred drugs for treating COPD (%)in Brazil, India, China and the US, 2010 108
Figure 44: Long-term management of COPD by physician type (%) in Brazil, India, China and the US, 2010 111
Figure 45: Method of COPD tracking (%)in Brazil, India, China and the US, 2010 113
Figure 46: Average number of points (out of 100) assigned to treatment attributes that influence COPD prescribing behavior in Brazil, India, and China, and the US, 2010 118
Figure 47: Average number of points (out of 100) assigned to device attributes in influencing COPD prescribing behavior in Brazil, India , and China, and the US, 2010 122
Figure 48: Branded versus generic drug use by country (%) in Brazil, India, China and the US, 2010 125
Figure 49: Confidence in using generics (rating from 1-10) in Brazil, India, China and the US, 2010 127
Figure 50: Different mechanisms of asthma and COPD, 2010 128
Figure 51: Level of difference between COPD and asthma treatment (rating from 1-10) in Brazil, India, China and the US, 2010 130
Figure 52: Treatment outcomes for COPD (ranked 1-5) in Brazil, India, China and the US, 2010 132
Figure 53: Level of patient compliance by country (%) in Brazil, India, China and the US, 2010 134
Figure 54: Top 5 challenges in COPD (weighted average for Brazil, China, and India), 2010 135
Figure 55: Likelihood of prescribing novel combinations (rated 1-5) in Brazil, India, China and the US, 2010 139

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