Physician's Weekly Article - Maximize Treatment Results for COPD

       Practical Tools for Managing COPD—Series #2

      This feature story is the second of a three-part series on "Practical Tools for Managing COPD" from Physician’s Weekly. The first part of this series was published in May and discussed strategies to accurately diagnose COPD. The series will conclude in August with a feature that evaluates methods for preventing COPD.

      A myriad of therapeutic options—pharmacologic, non-pharmacologic, and surgical—are available to treat symptoms and exacerbations associated with COPD, but decisions are not "one size fits all."

      When a patient is diagnosed with chronic obstructive pulmonary disease (COPD), it is critical for physicians to implement strategies to prevent disease progression and to use pharmacotherapy as needed to control symptoms. In more severe cases, the disease will often require the integration of several different treatment approaches. “COPD requires a symptom-driven treatment strategy,” says William C. Bailey, MD. “Once the disease has been diagnosed, the goals of therapy should be to prevent disease progression, relieve symptoms, improve exercise tolerance and overall health status, and to prevent and treat complications and exacerbations.”

      The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has created a guide for physicians who treat patients suffering from the disease or its complications, and continually updates its recommendations to incorporate new evidence into practice. The GOLD committee states that treatment goals should be reached with minimal side effects, but acknowledges that this can be challenging because patients with COPD commonly have comorbidities. “It’s important to individualize treatment goals,” says Dr. Bailey. “We need to collaboratively weigh the benefits and risks to the patient along with costs—both directly and indirectly—to the individual and his or her caretakers. An effective plan for managing COPD should involve assessing and monitoring the disease, reducing risk factors, and planning to manage stable disease and exacerbations.”

      Manage COPD at Each Stage

      According to the GOLD recommendations, avoiding risk factors to prevent disease progression and using pharmacotherapy as needed to control symptoms can help manage mild to moderate COPD (Stages I and II). A variety of treatment approaches together with a commitment from providers to continuously support the patient as the illness progresses is often required for severe (Stage III) and very severe (Stage IV) COPD. “It’s important to provide appropriate therapy at each stage of the disease in order to improve quality of life and to reduce symptoms and exacerbations,” Dr. Bailey says (Table 1). “COPD appears to be a disease in which we may change the natural history by reducing exacerbations. Fewer exacerbations may result in less severe lung function deterioration over time.”

      Effective Disease Management is Possible

      Good pharmacologic options are available for patients suffering from COPD, and Dr. Bailey says that use of bronchodilators and inhaled steroids has been shown to reduce the incidence of exacerbations. “Bronchodilator medications are critical to managing symptoms in patients with stable COPD [Table 2]. These agents can be prescribed on an as-needed basis early in the disease when symptoms occur infrequently. When symptoms are more regular, one or more long acting bronchodilators should be given. Inhaled glucocorticosteroids can effectively reduce exacerbations when the patient has an FEV1 [forced expiratory volume in 1 second] of below 50%. These agents can make a difference in a patient’s quality of life and can possibly lead to long-term improvements.”

      The GOLD program recommends that physicians managing patients with COPD provide patient education and health advice in addition to pharmacotherapy. Patients may also benefit from counseling on smoking cessation, physical exercise, and nutrition as well as continued nursing support. “Not every patient will require all of these interventions,” says Dr. Bailey, “and assessing the potential benefits of each approach at each stage of COPD is a crucial aspect to consider.”

      The armamentarium of agents to treat COPD continues to progress, according to Dr. Bailey. “We currently have prescription ß2-agonists such as salmeterol and formoterol, which last for 12 hours and a 24-hour anti-cholinergic, tiotropium. In addition, there are two approved products combining long-acting ß2-agonists and corticosteroids. The good news is that we have many effective treatments that can have a major impact on patients. COPD can no longer be considered an untreatable disease.”

      Offer Oxygen Therapy & Pulmonary Rehabilitation

      Long-term oxygen therapy is also an important treatment for patients with severe COPD, and can be used both in the hospital and at home. "Research shows that oxygen therapy can be effective in cases where patients have an arterial oxygen saturation level of 88% or less at rest or with exercise," says Dr. Bailey. "Clinical investigations have shown that long-term oxygen therapy at home increases quality of life and reduces the risk of death in COPD with severe hypoxemia. New studies are currently planned to explore if patients with more moderate levels of hypoxemia can benefit from oxygen therapy."

      The GOLD committee also notes that pulmonary rehabilitation can serve a valuable role in the treatment of COPD (Table 3). "One of the big issues with pulmonary rehabilitation is reimbursement for patients," Dr. Bailey explains, "but efforts are being made to provide these services to more COPD sufferers. Although pulmonary function doesn’t change significantly with this therapy, it can have a profound impact by improving a patient’s cardiovascular conditioning, increasing their exercise capacity, and improving their quality of life."

      Surgery Can Help, But Medications Still Necessary

      In patients with stage IV COPD, there are two types of surgery that can improve a patient’s quality of life and in some cases decrease mortality: lung volume reduction surgery (LVRS) and lung transplantation. However, Dr. Bailey says these procedures should only be considered after a patient undergoes a vigorous pulmonary rehabilitation program. "No physician should ever recommend LVRS or lung transplantation unless a patient with COPD is in the best shape possible. In fact, many patients who could be considered surgical candidates will use a combination of medications and pulmonary rehabilitation and subsequently avoid surgery because their condition improves so dramatically."

      Dr. Bailey says selecting candidates for LVRS requires that a patient remain short of breath even after maximum medications and completion of pulmonary rehabilitation. “In such patients, those with predominantly upper lobe emphysema as indicated by radioluciency on CT scans are better candidates and should receive a mortality benefit.

      "Lung transplantation has not been documented to have a mortality benefit," continues Dr. Bailey, "but is done to improve quality of life in patients who are not a candidate for LVRS or have deterioration after having received that surgery. Obviously, the patient must be free of comorbidities and psychologically suitable for the complex long-term course of immunosuppressive therapy for the continued success of this surgery."

      Dr. Bailey has indicated to Physician’s Weekly that he has or has had the following financial interest: AstraZeneca, Sanofi-Aventis, Boehringer-Ingelheim, GlaxoSmithKline, Integrated Therapeutics, Novartis, Pfizer, and Schering-Plough.