Understanding COPD Diagnosis and Management
During the NAMCP 2018 Spring Managed Care Forum, Sanjay Sethi, MD, division chief of Pulmonary, Critical Care, and Sleep Medicine at the University of Buffalo, outlined the recent clinical advances in the diagnosis and treatment of COPD.
Dr Sethi started his presentation by explaining the current definition of COPD. He said that it is a common, preventable, and treatable disease characterized by persistent respiratory symptoms and airflow limitation. He added that the disease is usually caused by substantial exposure to noxious particles or gases. Further, COPD leads to structural changes caused by chronic inflammation of the lungs and chronic respiratory symptoms.
According to Dr Sethi’s presentation, 15 million patients have been diagnosed with COPD in the United States. Additionally, 63% of Americans with COPD have not been diagnosed. He explained that many cases of COPD are not identified until significant disease progression has occurred. He added that the majority (70%) of undiagnosed COPD cases are in patients younger than 65 years.
Dr Sethi cited data showing that COPD accounts for around $30 billion in direct costs and an additional $20 billion in indirect costs.
According to Dr Sethi, the majority of patients diagnosed with COPD do not receive any treatment for the disease. Research based on more than 50,000 medical claims showed that most newly-diagnosed COPD patients are not prescribed long-term maintenance therapy.
Dr Sethi explained that diagnosing COPD requires that all patients who have been exposed to any COPD risk factors be considered for COPD screening. Risk factors include smoking, exposure to air pollution, occupational pollution, family history of COPD, or patients older than 40 years. Symptoms include shortness of breath, chronic cough, chronic sputum production, and wheezing. In order to differentiate from asthma, spirometry is required to make an accurate diagnosis.
Dr Sethi said that there are four components to COPD management, including assessing severity and monitoring disease, reducing risk factors, managing stable COPD through pharmacologic and nonpharmacologic treatment, and managing exacerbations.
“Pharmacologic treatment for COPD should be individualized, matching the patient’s therapy to their needs,” Dr Sethi said. “Nonpharmacological intervention such as pulmonary rehabilitation should also be individualized to maximize personal functional gains.”
He added that individualized pharmacologic treatment should be based on severity of symptoms, history of exacerbations, side effect profile, drug cost and accessibility, and patient response. Dr Sethi also explained that integrated care can play a role in COPD treatment and needs to be individualized to the stage of the patient’s COPD.
Pharmacologic options for managing COPD include use of short-acting bronchodilators, long-acting bronchodilators, anti-inflammatories with inhaled corticosteroid + long-acting beta antagonists, PDE-4 inhibitors, and oral steroids.
First-line treatment should be initiated upon diagnosis of mild COPD, Dr Sethi said. Regular treatment with long-acting bronchodilators should be added at the moderate disease stage. At the severe stage, COPD patients should be prescribed glucocorticosteroids if they experience repeated exacerbations, with long-term oxygen added at the very severe stage.
Dr Sethi explained that adherence issues need to be taken into consideration when prescribing treatment for COPD. Adherence to COPD medication is poor, according to the presentation, with 54% adherence to long-acting beta antagonists and 40% adherence to inhaled corticosteroids.
He said that patients are also more likely to adhere to medication when they perceive their clinician as a “lung disease expert.”
He said that likely barriers to COPD treatment adherence include poor education regarding COPD and disease management, a perceived burden of medication regimen, difficult using devices, depression, costs, and adverse effects. Dr Sethi noted that these problems can be mitigated with education in smoking cessation and COPD management. Additionally, he explained that some nonpharmacologic strategies include vaccination, pulmonary rehabilitation, surgical alternatives, and oxygen therapy.
“COPD is heterogeneous in its development, progression, and clinical expression,” Dr Sethi concluded. “Better disease characterization should lead to more personalized treatment.”
—David Costill
