Five tips on improving outcomes in patients with COPD

The trajectory of chronic obstructive pulmonary disease (COPD) tends, unfortunately, to be a downward one. For some patients this is a very gradual slope with minimal day-to-day symptoms, while for others the burdens of COPD are front and centre much of the time. Wherever a patient is on this trajectory, slowing the decline is a reasonable goal; however, for many patients their primary aim is to live more comfortably with less breathlessness and with as minimal burden as possible.1 The management of COPD, whether through multiple inhaler use, vaccinations or management of multiple comorbidities, places the community pharmacist at the forefront, opening up a variety of important avenues to enhance patient care and minimize burden. Aside from the obvious importance of helping patients with smoking cessation in those continuing to smoke, here are five tips to help ensure COPD patients are achieving the care and outcomes that are best for them.Periodically assess inhaler technique and adherenceArguably the most recognized role pharmacists play with COPD patients is in helping patients optimize their medications by assessing inhaler technique and gauging adherence. Assessing technique is important not only for patients already using a specific device, but also prior to dispensing a prescription for the first time.A survey of Canadian outpatient prescribers found that 52% prioritized their own experience when prescribing inhalers, with less attention to what might work best for patients, such as inspiratory flow rate, physical attributes (e.g., hand dexterity) or cognitive ability.2 With multiple device options available for most medication classes and combinations, helping to determine whether a particular device makes sense for your individual patient can minimize difficulties down the road. To support your assessments of the “what” and “how,” pharmacists can make use of easily accessible high-quality resources.3-5While proper technique is essential, we also need to know if patients are actually using their inhalers. Adherence rates in COPD can be as low as 30%–50%.6,7 After determining if they’re using their inhaler(s), keep in mind there are often multiple factors impeding adherence. Community pharmacists tend to be the best equipped to help resolve the “if not, why not” issues, such as side effects, cost, lack of efficacy, or confusion with the device or regimen.Ask questions to assess need and preferenceBefore we assess adherence with an inhaler, we should first be asking if the inhaler is necessary. As management guru Peter Drucker said, “There is surely nothing quite so useless as doing with great efficiency what should not be done at all.”8 Rational medication decisions for chronic conditions like COPD should be made with the patient, considering potential benefits, harms and patient values. COPD guidelines tend to take the generally reasonable stepwise approach to management,9,10 but we need to recognize that just because a patient can take a step, it doesn’t mean they should (or will want to). Beyond the first step up to a long‐acting muscarinic antagonist (LAMA) or long‐acting beta‐agonist (LABA), the gains of subsequent steps are incremental at best, sometimes with questionable benefit-to-burden balance.11 Although having all-in-one inhalers containing two or three medications allows for fewer inhalers, this still results in multiple ingredients with potential adverse events and greater costs, increasing patient burden.In order to be on the same page as the patient, ask questions to determine if expectations are being met for symptom improvement, functionality and exacerbation reduction. It’s also important for pharmacists and patients to realize that COPD symptoms can fluctuate seasonally, weekly or even daily in many patients,12,13 meaning that asking these questions is necessarily a repetitive process to establish a better overall picture. Frequent encounters with chronic disease patients make community pharmacists well-placed to have these frequent mini-assessments that help you, your patient and the prescriber take the next steps, either up or down.Keep pulmonary rehabilitation on your radarA large body of evidence supports the benefits of pulmonary rehabilitation for improvement in COPD symptoms, quality of life and exercise capacity, and reduction in exacerbations.14,15 If you’re able to be a direct referral source, that’s great, but even prompting your patient’s primary care provider can go a long way to jumpstart the referral process to local programs existing in many regions across the country. Not all patients will have the time or desire to commit to a program, but being familiar with the programs in your area allows you to get the ball rolling by providing the necessary information to your interested patients, as well as collaborating with their primary care provider in the referral process.Don’t forget about vaccinationsConsidering the often-underwhelming benefits of COPD inhaler therapies (despite many ingredients and many devices), comprehensive care beyond inhalers including up-to-date vaccinations is important to help minimize the complications of COPD. Influenza, pneumococcal, COVID and respiratory syncytial virus (RSV) vaccinations are all recommended for most patients with chronic lung conditions;16 however, the bulk of evidence for COPD patients resides with influenza and pneumococcal vaccinations, both resulting in a reduction in exacerbations.17-19 As part of immunization tracking processes in your pharmacy, flagging COPD patients in your system, especially those with more severe disease, is another way to further enhance comprehensive care for this at-risk group.Recognize the bigger health pictureUp to 50% of all hospitalizations and a quarter to a third of all deaths in patients with COPD are related to cardiovascular disease.20 It’s important to keep in mind the relatively large potential for cardiovascular event reduction that can be accomplished through rational blood pressure control and statin use when appropriate. Although not directly affecting COPD symptoms, reduction of vascular events can minimize overall health burden and the detrimental effects on overall functioning in a patient with already compromised functional status. Recognizing this and the continual interplay between comorbid conditions in this complex patient population will allow for more nuanced and better prioritized medication decision making.SummaryPharmacists have a significant opportunity to ensure that comprehensive care is provided for their patients with COPD. Frequent encounters for new inhalers and refills allow for continued points of contact for assessment of inhaler technique, adherence and indication. Be ready to advocate for escalation or de-escalation of therapy, including not only inhaler decisions, but also through involvement in the pulmonary rehabilitation process. In addition, ensuring appropriate immunizations and recognizing the importance of multimorbidity in medication management decisions will go a long way to achieving the ultimate goal of patient-informed comprehensive care for the COPD patients in your practice.Jamie Falk (Jamison.Falk@umanitoba.ca) is an Associate Professor, Colllege of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba.References:Cook NS, Criner GJ, Burgel P-R, et al. People living with moderate-to-severe COPD prefer improvement of daily symptoms over the improvement of exacerbations: a multicountry patient preference study. ERJ Open Res 2022;8:00686-2021.Frank IR, Falk J, Korownyk C, et al. How patient-centred are inhaler device choices? A survey of Canadian prescribers. Can J Hosp Pharm 2024;77(2):e3507.Cascades. A clinical guide to inhalers in Canada. (accessed December 4, 2024)RxFiles. How to pick an inhaler. Updated September, 2024. (accessed December 4, 2024).RxFiles. Asthma & COPD: Inhalation devices chart. Updated November, 2023 (accessed December 4, 2024).Turégano-Yedro M, Trillo-Calvo E, Navarro I Ros F, et al. Inhaler adherence in COPD: a crucial step towards the correct treatment. Int J Chron Obstruct Pulmon Dis 2023;18:2887-93.López-Campos LJ, Quintana Gallego E, Carrasco Hernández L. Status of and strategies for improving adherence to COPD treatment. Int J Chron Obstruct Pulmon Dis 2019;14:1503-15.Drucker PF. Managing for business effectiveness. Harv Bus Rev 1963;41(3):53-60.Bourbeau J, Bhutani M, Hernandez P, et al. 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD. Am J Respir Crit Care Med 2023;7(4):173-91.Global Initiative for Chronic Obstructive Lung Disease. 2024 Gold report. (accessed December 4, 2024).BC Provincial Academic Detailing (PAD) Service. COPD: triple therapy and device choice. (accessed December 4, 2024).Jenkins CR, Celli B, Anderson JA, et al. Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study. Eur Respir J 2012;39:38-45.Kessler R, Partridge MR, Miravitlles M, et al. Symptom variability in patients with severe COPD: a pan-European cross-sectional study. Eur Respir J 2011;37:264-72.McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015(2):CD003793.Puhan A, Gimeno-Santos , Cates J, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016(12):CD005305.Government of Canada. Immunization of persons with chronic diseases: Canadian Immunization Guide. Updated November 12, 2024. (accessed December 4, 2024).Kopsaftis , Wood-Baker , Poole . Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2018(6): CD002733.Bao W, Li Y, Wang t, et al. Effects of influenza vaccination on clinical outcomes of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Age Res Rev 2021;68:101337.Walters JAE, Tang JNQ, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017(1): CD001390.Morgan AD, Zakeri R, Quint JK. Defining the relationship between COPD and CVD: what are the implications for clinical practice? Ther Adv Respir Dis 2018;12:1-16.

Five tips on improving outcomes in patients with COPD

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