Sex, gender, and health: the need for a new approachBMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7320.1061 (Published 03 November 2001) Cite this as: BMJ 2001;323:1061
All rapid responses
Tiotropium, an inhaled long-acting antimuscarinic bronchodilator drug, was launched in the UK for the treatment of chronic obstructive pulmonary disease in September 2002. In order to determine the factors influencing prescription of this new treatment we reviewed all patients with a diagnosis of COPD attending two hospital clinics for the whole of 2003 using prospectively collected information from a research audit database. Patients were classified as ‘tiotropium positive’ if they were taking tiotropium, if the clinic doctor recommended that their general practitioner should prescribe it or if they had tried it but stopped it because of side effects. Thus the outcome measure here is an amalgam of prescribing decisions in this hospital, at other hospital clinics and by patients’ general practitioners.
One hundred and thirty-five patients – 82(61%) male were identified. Tiotropium had been used by, or recommended for, 46% of the men but only 26% of the women (Chi2 p=0.020). Patients in the tiotropium positive group did not appear to have more severe disease or differing body habitus (see table) Exacerbation rate, defined as 0-1, 2-4, or >4 exacerbations requiring antibiotic treatment per year, was not different between groups (p=0.13). The tiotropium positive patients were significantly more likely to be using a long-acting beta 2 agonist (p=0.03) but use of the latter drugs did not appear to be related to disease severity, exacerbation frequency or gender. An incidental finding was that of the 52 tiotropium positive patients five (9.6%) had stopped taking tiotropium because they found it unhelpful and 9 (17%) because of side effects. Although this is a relatively small sample this appears to be a higher failure rate than has been reported in clinical trials and may better reflect normal clinical experience(1).
We conclude that in this clinic population, the decision to use tiotropium was more common in men and not linked to objective measures of disease severity. Since COPD prevalence in women is increasing(2) and potentially significant gender biases in the management of other conditions have previously been demonstrated(3) we believe our finding warrants further more detailed investigation and should prompt those treating patients with this condition to review their practice.
Characteristics of patients recommended or not recommended tiotropium Tiotropium positive Tiotropium negative n=52 n=83 Age 62.8(9) 60.3(11) Body mass index 23.8(6.0) 23.7(4.3) FEV1 %predicted 31.0(14) 35.2(17) Diffusing capacity %predicted 39.5(20) 36.7(19) Residual volume %predicted 220(69) 217(64) On long acting Beta2 agonist 88% *66% Home nebuliser 34.9% 34.6% All non significant except *P<_0.05 meansd.="meansd." fev1="fev1" forced="forced" expiratory="expiratory" volume="volume" in="in" one="one" second.="second." _="_" pre="pre"/>
1. Casaburi, R., et al., The spirometric efficacy of once-daily dosing with tiotropium in stable COPD: a 13-week multicenter trial. The US Tiotropium Study Group. Chest, 2000. 118(5): p. 1294-302.
2. Soriano, J.B., et al., Recent trends in physician diagnosed COPD in women and men in the UK. Thorax, 2000. 55(9): p. 789-794.
3. Williams, D., K. Bennett, and J. Feely, Evidence for an age and gender bias in the secondary prevention of ischaemic heart disease in primary care. Br J Clin Pharmacol, 2003. 55(6): p. 604-608.
Competing interests: Characteristics of patients recommended or not recommended tiotropium Tiotropium positive Tiotropium negative n=52 n=83 Age 62.8(9) 60.3(11) Body mass index 23.8(6.0) 23.7(4.3) FEV1 %predicted 31.0(14) 35.2(17) Diffusing capacity %predicted 39.5(20) 36.7(19) Residual volume %predicted 220(69) 217(64) On long acting Beta2 agonist 88% *66% Home nebuliser 34.9% 34.6% All non significant except *P