Answers to Common Challenges in the Management of Patients With COPD

Course Director

Antonio R. Anzueto, MD

Antonio R. Anzueto, MD
Professor of Medicine
University of Texas
Health Science Center at San Antonio
San Antonio, Texas


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Part 2 of a 2-part series

Dr. Anzueto provides expert feedback to the questions submitted by your peers during a recent survey on this topic.

Overview

Current evidence-based, best-practice recommendations for the management of chronic obstructive pulmonary disease (COPD) are intended to be a core resource for physicians involved in the care of patients with this disorder. The latest update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) document addresses the growing complexity of managing patients with COPD, and reflect the need for individualization of care. In applying these recommendations to patient care, clinicians will have greater flexibility in establishing treatment goals as well as selection of therapy.


Disclosures

This activity is supported by educational grants from AstraZeneca Pharmaceuticals LP and Novartis Pharmaceuticals Corporation.
Additional support provided by Penn State College of Medicine and Answers in CME.

Course Director
Antonio R. Anzueto, MD, has a financial interest/relationship or affiliation in the form of:
Consultant for Boehringer Ingelheim Pharmaceuticals, Inc.; Forest Laboratories, Inc.; GlaxoSmithKline; and Novartis Corporation.
Grant/Research Support from GlaxoSmithKline.
Medical Director
Kadrin Wilfong, MD
Answers in CME, Inc.
Kadrin Wilfong, MD currently has no financial interests/relationships or affiliations in relation to this activity.

Answers in CME staff who may potentially review content for this activity have disclosed no relevant financial relationships.

Penn State College of Medicine staff and faculty involved in the development and review of this activity have disclosed no relevant financial relationships.

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Clinicians now have many drugs to choose from for patients with COPD—long-acting beta-agonists, long-acting muscarinic antagonists, and inhaled corticosteroids. How do we choose from among these therapies?

Dr. Anzueto: In order to determine the medication that we want to use, we should evaluate the patients based on the different risks and the combination of disease severity, symptoms, and [the risk of] having future events, such as COPD exacerbation or hospital admissions. The GOLD (the Global Initiative for COPD) has recommended that we should stratify our patients into four groups based on the complexity of the disease: Patients in Group A will be individuals with [a] low risk for exacerbation and not very symptomatic; patients in Group B have few exacerbations, but are more symptomatic; while Group C and D are patients who have more severity of the disease, are having frequent exacerbations and/or hospitalizations, and more severe symptoms.1

So once you have evaluated your patients and identified in which group they fall, then we can make decisions about therapy. For example, patients who have symptoms related to their COPD [Groups B to D], the first choice of therapy is the use of long-acting bronchodilators, either a long-acting muscarinic antagonist or a long-acting beta2 agonist (LAMAs or LABAs). Then therapy will be escalated based on the frequency of exacerbations or symptoms. Our goal will be to improve patients' lung function and symptoms the best we can, and we may be able to achieve this [even] in patients with milder disease. For example, even though the recommended first choice of therapy for Group B patients, according to the current GOLD recommendations, is regular treatment with a long-acting anticholinergic or long-acting beta2 agonist, they also suggest considering regular treatment with [a] combination of these bronchodilators. The ultimate objective is to improve patient symptoms as much as possible.

In patients who remain symptomatic despite having this combination of therapy, we can also consider the use of inhaled corticosteroids or eventually even theophylline. Theophylline is usually indicated in patients with very severe disease who are already receiving combination therapy with an inhaled corticosteroid and long-acting bronchodilators. This medication is used at low doses, 100 to 200 mg/d, and its main effect is enhancing the steroid receptor activity.

Other medications that we have available in patients who have more severe disease are the phosphodiesterase-4 [PDE-4] inhibitors. These medications decrease inflammation and may promote airway smooth muscle relaxation. Roflumilast is an oral PDE-4 inhibitor that is approved for use in patients with severe COPD who have a history of chronic bronchitis and exacerbations and has been shown to significantly reduce the frequency of exacerbations.2-5

When patients are having frequent exacerbations, and they are already on long-acting bronchodilators, the GOLD initiative suggests to add inhaled corticosteroids. If they have chronic bronchitis, you can also use roflumilast.

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What would you recommend to practicing pulmonologists as a practical approach to assessing potential comorbidities in a patient with COPD undergoing treatment who remains symptomatic? As an example, how would you manage an elderly patient with symptomatic disease and history of heart disease?

Dr. Anzueto: The GOLD initiative has placed a strong emphasis [on the fact] that patients with COPD have significant incidence of comorbid conditions, and the most frequent of these comorbid conditions is cardiovascular disease.6 The coexistence of COPD and cardiovascular disease, as well as the overlap symptoms in patients with these conditions, makes [it] difficult to try to assign patients to one or other of these diseases. Especially in elderly patients, this could be a significant challenge.7

My recommendation is, when we deal with these patients, first we need to be sure that we have maximized their respiratory medications based on the severity of the disease and the risk for future events. And [if] despite this, patients continue to remain symptomatic, it's appropriate to refer to a cardiologist, to do [an] extensive assessment and understand if they have coronary artery disease that is symptomatic and/or pulmonary hypertension.

In these patients, once they are referred to a cardiologist, and they perform additional exams, it's very likely that the recommendation will be the use of pharmacotherapy. So coronary artery disease should be treated according to the current guidelines, and there is no evidence that the treatment should be different in the patients with COPD. These therapies may include beta blockers, the statins, aspirins, etc. All of these medications that have been shown to be cardioprotective will have a significant impact in this patient population. The key message is that we should keep in mind that detection and management of comorbidities is crucial for the care of patients with severe COPD, and clinicians should look for these conditions in order to ensure the patients are receiving appropriate therapy for them.7,8

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What treatment strategies can be used to prevent or reduce the risk of exacerbations in patients with COPD and keep them at the highest possible level of functioning?

Dr. Anzueto: First, we have recognized that exacerbations increase the morbidity and mortality in patients with COPD, and clinical studies have demonstrated that the use of long-acting bronchodilators, long-acting anticholinergics, or long-acting beta2 agonists alone or in combination with inhaled corticosteroids significantly reduces exacerbations and even hospitalizations.9-11 This reduction in exacerbations has been shown to have an impact on the natural history of the disease. The use of pharmacotherapy, together with other measures that can reduce exacerbations such as influenza and pneumococcal vaccination and pulmonary rehabilitation, will impact the patients in ways we never suspected before.

If a patient continues to have exacerbations despite the use of appropriate pharmacotherapy, we need to consider [that] they may have a comorbid condition. For example, comorbidities that we know that frequently occur in patients with COPD like cardiovascular disease, metabolic syndrome, osteoporosis, gastroesophageal reflux, may also exacerbate the exacerbations.

All these conditions are [a] frequent cause of death in patients with COPD, and they will occur at any level of severity of lung function. But if we go back and ask ourselves why are our patients having frequent exacerbations, despite being on appropriate pharmacotherapy, [the answer is] they may need to receive appropriate treatment for their coronary artery disease or for their gastroesophageal reflux, which may be responsible for these events.

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References

  1. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014. Available from: http://www.goldcopd.org/.
  2. Rennard SI et al. Chest. 2006;129:56-66.
  3. Rabe KF et al. Lancet. 2005;366:563-571.
  4. Calverley PM et al. Am J Respir Crit Care Med. 2007;176:154-161.
  5. Calverley PM et al. Lancet. 2009;374:685-694.
  6. Finkelstein J et al. Int J Chron Obstruct Pulmon Dis. 2009;4:337-349.
  7. Rutten FH et al. Eur Heart J. 2005;26:1887-1894.
  8. McAllister DA et al. Eur Respir J. 2012;39:1097-1103.
  9. Vestbo J; TORCH Study Group. Eur Respir J. 2004;24:206-210.
  10. Tashkin DP et al. N Engl J Med. 2008;359:1543-1554.
  11. Vogelmeier C et al. N Engl J Med. 2011;364:1093-1103.

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This activity is supported by educational grants from AstraZeneca Pharmaceuticals LP and Novartis Pharmaceuticals Corporation.
Additional support provided by Penn State College of Medicine and Answers in CME.

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Q&A: How to Apply the Latest Evidence and Recommendations to Practice to Improve the Treatment of Patients With COPD

  1. Updates in the Management of COPD: Best Practices and Emerging Therapeutic Options