Medical Chronicle recently hosted a CPD-accredited webinar on chronic obstructive pulmonary disease (COPD) – improving outcomes. This webinar was sponsored by Cipla and presented by Prof Guy Richards. The following article is based on his presentation.
If you would like to watch a recording of this webinar, go to: https://event.webinarjam.com/go/replay/652/w8948co7qiry5sorvux
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA, 2017).
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases (GOLD 2017).
Asthma-COPD overlap [not a definition, but a description for clinical use] (ACO) is characterised by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Asthma-COPD overlap is therefore identified in clinical practice by the features that it shares with both asthma and COPD.
This is not a definition, but a description for clinical use, as asthma-COPD overlap includes several different clinical phenotypes and there are likely to be several different underlying mechanisms.
Over 80 million people have moderate-to-severe COPD. Half of the patients die in under 10 years of diagnosis. It is currently the fourth leading cause of death and predicted to be the third leading cause by 2020. In 2012, 3 million people died of COPD.
GOLD: Goals of therapy
- Relieve symptoms
- Improve exercise tolerance
- Improve health status.
- Prevent disease progression
- Prevent and treat exacerbations
- Reduce mortality.
Bronchodilator therapy deflates the lung, creating improvement in flow. Forced expiratory volume (FEV1) calculates the amount of air that a person can force out of their lungs in one second. Bronchodilator therapy creates improvement in volumes – forced vital capacity (FVC) and Inspiratory capacity (IC).
Bronchodilators in stable COPD are central to symptom management. Short-acting beta agonists (SABAs) and Short-acting muscarinic-antagonist (SAMAs) relieve symptoms.
Combinations are better:
- long-acting bronchodilator combinations (LABAs) and long-acting muscarinic antagonists (LAMAs) significantly improve pulmonary function tests (PFT), shortness of breath (SOB), quality of life (QOL) and decrease acute exacerbations (AE)
- LAMAs decrease AE compared to LABA & decrease hospitalisation
- Combination LAMA/LAMAs increase FEV1 and decrease symptoms and AEs compared to monotherapy
- Tiotropium increases exercise performance during rehabilitation.
COPD not controlled on one bronchodilator should be given two, with different mechanisms of action. This may allow lower doses, decrease adverse effects, simplify regimens and improve compliance. LABA/LAMA induces larger bronchodilation and improves many patient-reported outcomes.
- A LABA/ and LAMA combination is superior to LABA, LAMA or LABA and inhaled corticosteroids (ICS) in reducing hyperinflation.
- Long-acting β2-agonist indacaterol/ long-acting muscarinic antagonist glycopyrronium (IND/GLY) is significantly superior to IND alone in increasing IC
- IND and the LAMA tiotropium (TIO) is significantly superior to TIO alone in improving IC
- The LABAs formoterol (FORM) and TIO significantly reduced end-expiratory lung volume (EELV) vs FORM.
Single inhaler triple therapy
An observational study on single-inhaler triple therapy vs dual bronchodilators in real-world clinical practice (UK’s Clinical Practice Research Datalink) showed:
- Patients not on ICS that initiated single-inhaler triple therapy (n=4106) or single-inhaler dual bronchodilator(n=29 702), were followed for one year; a hazard ratio (HR) of a first moderate or severe AE on triple vs dual was 1.08 (1.00–1.16)
- HR of AE was lower with triple only in patients with ≥2 prior exacerbations, with prior asthma diagnosis and blood eosinophil count >300 cells per µL.
- Severe pneumonia (HR 1.50, 95% CI 1.29–1.75) was increased with triple therapy.
Smoking cessation is imperative (this includes cannabis). Pharmacotherapy reduces symptoms, frequency and severity of AEs and improves health-related quality of life.
Individualised pharmacotherapy is important. Take into account the ABE classification system, cost, response, preference and device. Assess inhaler technique regularly. Influenza and PCV13 vaccines reduce lower respiratory tract infections. Physical rehabilitation improves symptoms and health-related quality of life.