Pharmacological treatment of COPD

The Canadian Thoracic Society published evidence-based guidelines in 2023 on the pharmacological treatment of chronic obstructive pulmonary disease (COPD). Keeping up to date with the latest advice on the diagnosis and management of COPD is important, experts say.“The field is changing rapidly and you need trusted sources of information,” said Dr. Darcy Marciniuk, senior author of the guidelines, an associate vice president of research and a professor of medicine at the University of Saskatchewan in Saskatoon.“It follows along with raising expectations for management and outcomes,” Dr. Marciniuk explained. “There are so many effective pharmacologic, and also non-pharmacologic and other interventions, that can make a big difference. Expecting more has become our new reality, a realistic reality.”Diagnose and evaluateCOPD is being unrecognized, said Dr. Jean Bourbeau, lead author of the guidelines, director of the COPD clinic and pulmonary rehabilitation program at the McGill University Health Centre and professor of medicine at McGill University in Montreal. “Case finding starts with the proper evaluation of groups of patients at risk,” he said. For example, watch for COPD in patients who smoke, patients who report a change in their breathing or a change in physical activity and those with a long-term productive cough.Order a spirometry test to diagnose COPD. In 2022, the Canadian Thoracic Society and Choosing Wisely Canada ran a campaign promoting the need for lung function testing when diagnosing COPD. Results from an observational study in the U.S. suggests physicians who diagnose COPD without spirometry are likely to underestimate the disease severity. This could lead to inappropriate or inadequate treatment.While spirometry is important, there’s variation in how COPD presents and airflow obstruction can only partially assess the disease’s severity in each patient. Physicians must assess symptom burden and risk of exacerbations to determine the best pharmacotherapy. The most significant symptom is dyspnea, but it can be difficult to evaluate because people adapt their behaviours to accommodate the breathlessness. Dr. Bourbeau suggested using tools such as dyspnea scales, including the modified Medical Research Council (mMRC) dyspnea score. Symptom burden can also include any limitation on physical activity and an impaired health status. The guidelines also use the COPD assessment test, or CAT, as a measure of symptom burden.Determine the patient’s history, risk and severity of acute exacerbations. For example, an acute episode that requires a steroid like prednisone is moderate, but one that prompts an emergency department visit or hospitalization is considered severe, Dr. Bourbeau said. “This is going to be important, because this is going to be the base on which the physician will decide, ‘What is the treatment for my patient?’”Treatment for patients with no acute exacerbations, low burden of symptomsThis group includes patients with low symptom burden, for example, with an mMRC score of one or a CAT of less than 10 and no risk or history of exacerbations. These patients can be prescribed monotherapy using a long-acting muscarinic antagonist (LAMA) or a long-acting beta agonist (LABA).All patients can also benefit from non-pharmacological interventions, including a smoke-free environment, vaccinations, exercise and, in some patients, pulmonary rehabilitation.Low risk of acute exacerbations but moderate burden of symptomsConsider LABA/LAMA dual therapy for a patient with an increased burden of symptoms but a low risk of exacerbations, “meaning that in the previous year, the patient has not had more than one moderate exacerbation,” Dr. Bourbeau clarified.If patients aren’t responding to medication, consider referring them to a respirologist.High risk of acute exacerbations and high burden of symptomsPatients who have a high risk of exacerbations are at the highest risk of death. For example, these patients may have experienced one severe or two moderate exacerbations in the past year. The Canadian Thoracic Society recommends triple therapy, with LABA/LAMA and an inhaled corticosteroid in one device for these patients. Dr. Marciniuk noted that the Canadian Thoracic Society conducted a meta-analysis of multiple randomized clinical trials and results suggested that triple therapy, “improved lung function, enhances quality of life, reduces the risk of moderate and severe exacerbation and then reduces the risk of death.” The meta-analysis is published as a supplementary document to the guidelines.“We’re going to a place now where we want our patients on this therapy regardless of symptoms; no different from how we treat hypertension,” Dr. Marciniuk said.Physicians may consider adding oral agents in select patients taking triple therapy if exacerbations continue. The guidelines note physicians may consider prophylactic macrolides in patients with continued exacerbations or PDE-4 inhibitors (e.g., roflumilast) or mucolytic agents (e.g., N-Acetylcysteine) in patients with chronic bronchitis.It may be a tough grind trying to help patients with this level of disease, with the patient’s medical history of other conditions and affordability of medications adding to the complexity, Dr. Marciniuk said. Opt for team-based care and work alongside respirologists and allied healthcare professionals to help patients. While there may be tricky cases, “with all of us working together we can make a difference,” he said.Choosing the right deviceDual and triple therapy should be given in a single device.“There’s even evidence showing that patients that take a single device have a better outcome than people who take multiple devices,” Dr. Bourbeau said. “If it happens that you have a patient who takes multiple devices, you should make the effort to switch to a single device.”Having choice is both a benefit and a curse and selecting the best one for the patient can get overwhelming, Dr. Marciniuk said. There are options to consider with respect to the number of doses a day and whether it is a metered device. There are currently four dual therapy devices and two triple therapy devices available in Canada. “Many of them have not had head-to-head comparisons, unfortunately,” Dr. Bourbeau said.Basically, choose a device where the patient will be able to use the device properly. Patients may prefer a device that aligns with what they have successfully used in the past, “because convenience and familiarity always helps,” Dr. Marciniuk said.“It’s not to say that one is superior to the other, but it is to say that the right device should be selected based on the patient’s ability to take it and something the patient will prefer,” Dr. Bourbeau said.If the treatment isn’t working, or the patient is having trouble taking the medication, consider switching devices. There may be some trial and error to get the right one, Dr. Bourbeau said.In conversations about the device, ensure that you validate appropriate use and inhaler technique. Dr. Marciniuk said he connects patients with certified respiratory educators.He said that provincial health insurance programs are aligning more with the medical evidence when it comes to coverage for these devices.The Canadian Thoracic Society released a statement in 2023 about the environmental impact of certain inhalers. It includes the Choosing Wisely Canada recommendation that physicians prescribe an inhaler with a lower carbon footprint when there’s comparable efficiency between inhalers and when the physician has considered patient preference.Dr. Marciniuk encouraged physicians to keep up to date on COPD treatment. Seek out materials or resources from the Canadian Thoracic Society or American College of Chest Physicians (CHEST) or provincial lung associations, he said.

Pharmacological treatment of COPD

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