In this study COPD patients (n=180) were aware of the drug regimen but awareness regarding drug name and their adverse effects was poor. Similarly, 75% patients were aware of inhaler use technique but awareness regarding steps of breath holding and mouth gargling was poor. More than 2/3^rd of the participants had a perceived drug adherence score more than 50% with mean score of 4.71 out of 6. Most prescribed drug in the prescriptions was inhalational tiotropium bromide and FDC was Theophylline + etophylline. Drugs salbutamol, levosalbutamol and theophylline + etophylline FDC were prescribed in lesser doses while formoterol +budesonide FDC was overprescribed.

There was male preponderance 175 (97.2%) in our study similar to the meta-analysis of population-based epidemiologic studies conducted to calculate gender specific global prevalence of COPD which concluded that the overall prevalence of COPD was higher in males i.e., 9.24% and 6.15% in females, respectively and when analysis was limited to populations with age cut off above 40 years, the prevalence was around 11.57% and 7.44%, for males and females respectively [9].

The mean age of the participants was 65±8.37 years. Similar finding was noted in a study conducted in Spain by Miravitlles M et al.,where a total of 4,574 COPD patients were included and the mean age of the population was 67.1 years [10]. Similarly, it was noted in a study conducted in India by Gupta A et al., majority i.e., 47 /60 (78.3%) COPD patients fell in the age category of> 51 years [11].

In the current study hypertension (22.8%) was the most common comorbidity seen. The possible mechanism that links the two is the systemic inflammatory response triggered by cigarette smoke or air pollution [12,13]. Similarly in a study done in Southwest Iran by Kiani FZ et al., hypertension was seen in 30.2% of the COPD cases [14].

In the drug treatment awareness questionnaire 52.8% participants scored more than 50% thus indicating that nearly 47% patients lacked sufficient drug treatment awareness. To avoid this, physicians must ask the patients to reiterate the medication names even in cases where patients may claim that they know about the names of medications. It is important for the patients to know about the names of their medication to avoid dispensing errors at the level of pharmacist. If the patients know about their medication names, they can themselves verify the same when the pharmacist is dispensing the medications [15].

Some studies assessing inhaler use technique in India also showed lesser compliance to inhaler use techniques. Study done in Haryana by Gupta A et al., showed that out of 60 COPD patients only 36% of the patients were compliant to the use of inhaler at the first visit [11] while a study done in Jaipur by Sehajpal Ret al., showed that correct inhaler use technique was observed only in 18 (21.17%) patients [17].

Knowledge about possible undesired effects of the prescribed drugs is of paramount importance as it will help patients identify them and bring it to the notice of the prescribing clinician who can then take further action. A study done in Gujarat by Joshi et al., showed that 78.6% patients were aware that medicines can cause ADRs but none of the respondents were aware of ADR reporting centre and 86.7% agreed to report ADR in the future [18].

According to Centres for Disease Control and Prevention patients with higher education have mortality rates less than half of those without lesser educationprobably due to their better understanding of disease and its treatment.

In COPD despite advancement of medical treatment, nonadherence to medication poses an important opposition to the disease management with an average reported adherenceof 40%–60% in COPD patients [19]. In this study we found that 73.3% (132 participants out of 180) of the participants were able to score more than 50% (i.e., >3 out of 6), in the drug treatment adherence questionnaire with a mean score of 4.71 out of a total score of 6. Thus, we can see that the adherence is satisfactory. A study assessing medication adherence in COPD patients done in Haryana by Gupta A et al., saw a 74% compliance to medications [11].

A systematic review done by Van Boven J et al., showed that non-adherence in COPD showed a clear association with increase in hospitalizations and mortality, worsening in quality of life and loss of productivity [20]. The presence of comorbidities increases the number of medications that the participants have to consume on a daily basis thus making it more complex to adhere to treatment leading to the decrease in adherence to medication with presence of comorbid conditions [20].

Considering the lack of studies pertaining to COPD prescription patterns in western India, there was a need to find the same in western India region [21-23].

Prescriptions of the last 3 months were also analysed for any changes with respect to the current visit prescription. Hence, at the end of the study, 223 prescriptions were obtained for analysis from the 180 participants that were enrolled in the study.

In our study the average number of drugs per encounter was found to be 4.04±1.1 (Mean ± SD). Contrary to this in a study done in India by Sawant MP et al., the average numbers of drugs / prescription in COPD patients admitted to medicine in patient department was 7 [24]. This, may be because the patients were admitted as severe cases warranting more drugs to be prescribed.

In this study it was seen that majority of the drugs were prescribed with their generic name (i.e., 77.6 %). Our study found that 62.5% of the drugs were available in the national essential drugs list and 50% of the drugs were available in the WHO essential drugs list.

The most common drug prescribed was tiotropium bromide inhaler (i.e., 100%).  Similar finding was seen in a study done in Kerala by Unni Aet al., in which it was seen that in COPD patients (n=237) the most commonly prescribed drugs were ipratropium (91.6%) followed by levosalbutamol (88.2%) [22]. In another study done in Karnataka by Udaykumar Pet al., it was seen that tiotropium was prescribed in 73/80 patients [25]. In low-income countries because of its low cost and easy accessibility this bronchodilator FDC is commonly prescribed it may be prescribed as an alternative in the absence of other bronchodilators [26] and the cases that come to a tertiary care hospital are mostly referral cases in whom methylxanthines are usually started previously as they might have received treatment from primary health centers where availability of other drugs is lower. This is in accordance with the WHO’s Prevention and Control of Noncommunicable Diseases: Guidelines for primary health care in low resource settings [27], hence when patients are referred to tertiary care hospital these drugs are not abruptly stopped but instead continued with lowering of the dose with time.

Limitations: Awareness for non-pharmacological treatment (chest physiotherapy) was not assessed. Patient perceived adherence was calculated and not the actual drug adherence.