Treatment Options for COPD

Orlando—In the United States, half of the 24 million people with chronic obstructive pulmonary disease (COPD) are undiagnosed. Still, a person dies from COPD every 4 minutes. The disease is the fourth leading cause of death and will be the third leading cause of death by 2020, according to Rob Sussman, MD, co-director, Pulmonary and Allergy Associates Clinical Research Center.

However, he said COPD is “almost completely preventable” and can be treated. At the NAMCP forum, Dr. Sussman discussed some of the treatment options and provided an overview of the disease. The presentation was supported by educational grants from AstraZeneca, Boehringer Ingelheim, and Novartis.

He mentioned the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines that were updated earlier this year. The report’s authors defined COPD as a preventable and treatable progressive disease that is associated with airflow limitation, abnormal inflammatory response to particles or gases, and significant extrapulmonary effects. Unlike asthma, which is characterized by reversible airflow limitation, COPD is not fully reversible.

COPD is commonly known as a disease of older men. However, Dr. Sussman said 65% of patients with COPD are women and 70% are <65 years of age. Each year, there are 1.5 million emergency department visits related to COPD, and the disease is associated with $42 billion in annual costs. Ninety percent of COPD cases are caused by smoking, according to Dr. Sussman. Other causes of COPD include work exposures, genetic factors, second-hand smoke, indoor and outdoor pollution, and childhood infections.

When assessing for COPD, healthcare professionals should ask patients about their health history and give them a physical examination, spirometry, or pulmonary function test. Symptoms of COPD include dyspnea, chronic cough, and chronic sputum production, while risk factors include tobacco use, occupation, and exposure to indoor or outdoor pollution.

People are considered to have COPD if their forced expiratory volume in 1 second (FEV₁) divided by their forced vital capacity is <70%. They have mild COPD if their FEV₁ is ≥80% than the predicted value, moderate COPD if their FEV₁ is from 50% to 79% of the predicted value, severe COPD if their FEV₁ is from 30% to 49% of the predicted value, and very severe COPD if their FEV₁ is <30% of the predicted value.

Treatment Considerations

Before considering treatment options, Dr. Sussman suggested healthcare professionals assess COPD symptoms, severity of the spirometric abnormality, frequency of exacerbations, and comorbidities. The GOLD guidelines mentioned the modified Medical Research Council questionnaire is used to assess symptoms. If people have ≥2 exacerbations within the past year or an FEV₁ <50% of the predicted value, these are indicators of high risk.

Dr. Sussman said symptoms are more important than spirometric staging and recommended assessing symptoms such as dyspnea, cough, sputum, and activity limitations at each visit. He also added that people with COPD should reduce their risk factors and undergo smoking cessation, avoid occupational exposures, and have a flu vaccine if appropriate.

During visits with patients, healthcare professionals are advised to ask about tobacco use, advise patients to quit, assess their willingness to quit smoking, assist in their attempts to quit, and arrange for follow-up visits. Smoking cessation involves pharmacotherapy and counseling.

Patient education is also important, according to Dr. Sussman. Examples include disease awareness, risk factor reduction, understanding how and when to use medications, recognizing early symptoms and symptoms of exacerbation, and understanding the need for nutrition, exercise, and a healthy lifestyle.

The goals of treatment include relieving symptoms, improving exercise tolerance and health status, reducing mortality, preventing disease progression, and preventing and treating complications and exacerbations.

There are numerous pharmacologic treatments available for COPD such as short-acting beta agonists, short-acting muscarinic antagonists, long-acting beta agonists, long-acting muscarinic antagonists, theophylline, phosphodiesterase type 4 (PDE-4) inhibitors, and oral steroids.

For mild COPD, patients begin with an influenza vaccination and add short-acting bronchodilators if needed. Patients with moderate COPD add regular treatment with ≥1 long-acting bronchodilators and rehabilitation if needed, while patients with severe COPD add inhaled glucocorticosteroids if they have repeated exacerbations. Patients with very severe COPD add long-term oxygen if they have chronic respiratory failure and consider surgical treatments.

Dr. Sussman recommended that all patients with COPD should undergo genetic, nutrition, and extrapulmonary assessments. High-risk patients include those who have early onset emphysema (<45 years of age), emphysema without risk factors, lower lobe bullous disease, strong positive family history of COPD, depression, coronary artery disease, and malignancy.

Another option is lung volume reduction surgery, which is used to improve breathing with COPD. Dr. Sussman cited the National Emphysema Treatment Trial that found there were limited indications for the surgery, including for patients with heterogeneous emphysema and poor exercise capacity.

According to the GOLD guidelines, patients with COPD should undergo lung transplantation if they have post bronchodilator FEV₁ <25% of the predicted value, resting hypoxia with a pulmonary artery oxygen level <60 mm Hg, hypercapnia, secondary pulmonary hypertension, and rapid deterioration.

COPD Exacerbations

Of patients with COPD, 77% have at least 1 exacerbation per year, while 50% to 75% of COPD costs are for exacerbations, according to Dr. Sussman. Frequent COPD exacerbations are associated with a lower quality of life and a higher rate of decline in lung function.

Dr. Sussman defined an exacerbation as “an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variation and leads to a change in medication.” Causes of exacerbations include infections and air pollution, but Dr. Sussman said the causes for one-third of exacerbations are unknown.

To treat exacerbations, he recommended inhaled beta-2 agonists and anticholinergics, oral steroids, and antibiotics if there are signs of infection. To reduce exacerbations, he suggested influenza vaccinations, tiopropium, PDE-4 inhibitors, and the combination of long-acting beta agonists and inhaled corticosteroids.

In the coming years, Dr. Sussman expects treatment options will include a once daily combination of long-acting beta agonists and inhaled corticosteroids, a combination of long-acting beta agonists and long-acting muscarinic antagonists, a triple combination of inhaled corticosteroids, long-acting beta agonists, and long-acting muscarinic antagonists, and endobronchial valve therapy.