COPD: The two biggest challenges and changes in treatment

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This story appears courtesy of Clinician Reviews.

By Lisa Hack

REPORTING FROM THE ANNUAL CARDIOLOGY, ALLERGY, AND RESPIRATORY DISEASE SUMMIT

SAN DIEGO—One of the most significant challenges related to the treatment of chronic obstructive pulmonary disease (COPD), according to physician assistant Gabriel Ortiz, MPAS, PA-C, DFAAPA, is getting health care providers to use spirometry. “Spirometry is essential to establish the diagnosis,” Ortiz explained in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit. Yet many providers, he continued, just assume they are dealing with COPD. “The only way to differentiate between COPD and asthma is with spirometry.”

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He believes that many health care providers avoid the diagnostic either because they perceive it as being too difficult and/or time-consuming to master or too expensive. But Ortiz insists it is not difficult and that it is “a billable, reimbursable medical expense.” “If providers used it for all of their patients with asthma, COPD, and cough, wheezing, and shortness of breath, the machine would probably be paid for in about 3 months,” he remarked.

Ortiz reported at the conference, held by Global Academy for Medical Education, that COPD, currently the 4th leading cause of death in the world, is projected to be the 3rd leading cause by 2020. Its burden is significant. Limited inspiratory capacity that worsens with activity and that increases the work of breathing significantly impacts quality of life. In fact, reports indicate that 25% to 60% of patients experience depression, Ortiz said.

A most important risk factor
Past or present cigarette smoking remains one of the most important risk factors for COPD, and cessation has the greatest capacity to influence the natural history of the disease, Ortiz said. In fact, Ortiz remarked, “Getting smokers to quit is probably the other biggest challenge with this disease.” He explains that while patients must have the desire to quit and make the decision to do so on their own, “We can provide the option and the information they need.” Ortiz likes to discuss with patients a plan for quitting and agree on a quit date. He says patients will often agree to something like, “I’d like to start reducing right after Thanksgiving,” or “I’d like to be smoke-free by summer.” If effective resources and time are dedicated to smoking cessation, Ortiz reported, long-term quit success rates of up to 25% can be achieved.

Treatment changes
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018 report (https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf) brings with it a new treatment recommendation, Ortiz said. “We used to recommend, and many providers still do, starting with a long-acting beta-agonist bronchodilator (LABA) and then adding an inhaled corticosteroid, much like we do in asthma,” Ortiz explained. But patients who require more than just a LABA should be given a long-acting muscarinic receptor antagonist (LAMA). “That’s the preferred treatment,” Ortiz said.

An inhaled corticosteroid would then be added as a 3rd agent, if necessary. “So, the order of therapy is now to start with a bronchodilator (either a LABA or LAMA), then add an agent from whichever of these 2 classes was not already started, and then add a corticosteroid,” Ortiz summarized.

Ortiz said that one of the most significant changes in the treatment of COPD is the recent availability of a therapy that combines an inhaled corticosteroid, a LAMA, and a LABA in one inhaler for once-daily dosing.

 

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