Treat COPD symptoms, solve problems

Chronic obstructive pulmonary disease (COPD) is on the rise worldwide, with cases predicted to reach nearly 600 million by 2050—a jump of 23% more than 2020, according to a Dec. 7, 2023, study in JAMA. Despite being preventable and treatable, the disease remains a leading cause of death in the United States, and primary care physicians are on the front lines of management.

That means staying up to date on medications, devices, and delivery techniques, which can change according to cost and patient characteristics, experts said. Effective management can be challenging, especially considering that most COPD patients have multiple chronic conditions.

"Primary care physicians are responsible for many illnesses, all of which have multiple guidelines and therapeutic strategies," said Fernando Martinez, MD, MS, chief of pulmonary critical care medicine at Weill Cornell Medicine in New York City and a member of the science committee for the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) report. "They're under a lot of pressure during a 15-minute appointment, and COPD recommendations are not the most straightforward."

"A simplified GOLD strategy will help primary care physicians dealing with multiple comorbidities," said Dr. Martinez. "Two basic questions should guide pharmacotherapy decisions: How symptomatic is the patient, and what is their risk of exacerbation?"

Initiating treatment

While mortality rates for most chronic diseases have been declining in the United States over the past several decades, deaths from COPD have doubled since 1969, according to a July 2022 study in Annals of Family Medicine. The article cited 2012 data indicating that an estimated 80% of COPD patients are managed in primary care.

"Primary care physicians need to have COPD on their radar because it is currently underdiagnosed and undertreated," said Nicola Hanania, MD, MS, FACP, director of the Airways Clinical Research Center at Baylor College of Medicine in Houston. "Most cases start with symptoms like shortness of breath and decreased activity that patients may not even bring up with their doctor."

Confirming a diagnosis of COPD can be challenging as many primary care physicians do not have spirometers on site, said MeiLan Han, MD, MS, chief of the division of pulmonary and critical care medicine at the University of Michigan in Ann Arbor. However, spirometry is essential to making an accurate initial diagnosis or confirming a previous diagnosis.

"One patient who was referred to me for mild COPD actually had interstitial lung disease," she said. "It's also common for COPD to be overlooked, such as when patients have frequent bouts of bronchitis that aren't recognized as exacerbations."

Once the diagnosis is confirmed, COPD treatment should be staged based on severity of symptoms and history of exacerbations, said May-Lin Wilgus, MD, a pulmonologist and assistant clinical professor of medicine at UCLA Health in Los Angeles.

"If the patient has breathlessness without exacerbations, start with long-acting bronchodilator therapy consisting of either a long-acting beta-agonist or long-acting muscarinic antagonist, or a combination if the patient is more symptomatic," she said. "If there is a history of exacerbations or elevated eosinophils, consider adding inhaled corticosteroids."

It's important to reserve inhaled corticosteroid therapy for those with exacerbations because inhaled steroids have been shown to increase the risk of pneumonia in COPD patients, she added. Long-acting bronchodilator therapy alone is the first-line option for most patients with mild to moderate symptoms.

Short-acting bronchodilator therapy should be used to control mild symptoms or as rescue therapy on an as-needed basis, said David Halpin, MD, consultant physician and honorary professor of respiratory medicine at the University of Exeter in Devon, United Kingdom, who also serves on GOLD's science committee. The GOLD report includes a chart of the most commonly used short- and long-acting beta-agonists and muscarinic antagonists (or anticholinergics).

Choosing an appropriate inhaler device is critical to the success of therapy, said Dr. Halpin. There are at least 22 different inhaler options, including dry-powder, metered-dose, and soft-mist inhalers, as well as nebulizers, according to GOLD, all of which have different techniques for effective use.

Inhalers should be tailored to individual patients' abilities and preferences, he said. For example, patients must be able to inhale deeply in order to use a dry-powder inhaler.

It's always preferable to prescribe a single type of inhaler and stick with it, said Dr. Martinez. In a 2021 study published in the Journal of the COPD Foundation, researchers found that the majority of patients cited forgetfulness as the reason for not taking their medications as prescribed.

"The lesson is that it's best to minimize the number of devices and doses per day that patients have to take," said Dr. Martinez, the study's lead author. "Complex regimens with multiple devices almost always equal low adherence."

Besides patient preference, cost and access are significant issues in selecting an appropriate therapy, said Dr. Hanania. If costs are high, many patients will defer to using a rescue inhaler, which is usually cheaper, while forgoing recommended maintenance therapy.

For example, he said, patients covered under Medicare Part D have different copays or co-insurance requirements for inhalers and related medications, depending on their specific plan and whether generic versions are available. Medicare Part B does not cover prescription drugs, in general, but includes coverage for nebulizers and associated drugs.

"There are times when you have to switch drug classes and inhalers just based on insurance coverage," said Dr. Han. "When patients have poor Medicare Part D coverage, we sometimes switch them to the nebulized format which is covered under Medicare Part B to help them afford inhaled medications."

Partnering with a pulmonologist can help primary care physicians sort through options and figure out the best plan for individual patients, said Dr. Wilgus.

"Pulmonologists deal with COPD every day and are very familiar with different classes and types of medications and the pros and cons of various devices," she said. "They can offer advice on what to do next if a particular medication isn't covered."

Ongoing management

Patients should be seen every three months in the first year after starting treatment to review symptoms and progress, said Dr. Halpin. Follow-up should include assessing response to inhaled therapy and adjusting and/or adding medications if breathlessness and/or exacerbations persist.

Simple, validated tools are available to help physicians assess symptom severity at follow-up, according to GOLD. For example, the Modified Medical Research Council (mMRC) Dyspnea Scale assesses severity of breathlessness on a scale of 0 to 4 points. The COPD Assessment Test (CAT), an eight-item questionnaire, is recommended to assess overall health status.

Scoring at least 2 on mMRC or 10 of 40 on CAT is cause for concern, said Dr. Han. CAT, which has been programmed into some major electronic health record systems, offers a more detailed look at the patient's costs, activity level, breathing status, and sleeping habits and is easy to administer in the primary care setting.

If symptoms persist on initial therapy, ask a series of questions to determine next steps, said Dr. Halpin. For example, have they been taking their medications? Have they filled their prescriptions (check pharmacy records if possible)? Are they able to use their device correctly?

Patients should bring their inhaler devices to every appointment to evaluate that last question, he added. A physician or a qualified staff member should observe their technique and provide tips for improvement when necessary.

"Lots of people use devices incorrectly and therefore are not getting the benefit of their medications," said Dr. Halpin. "That must be determined before you considering changing or escalating therapy."

Consider adding a second long-acting bronchodilator if a patient continues to experience shortness of breath on a single medication, said Dr. Han. If they report exacerbations on dual bronchodilator therapy, it might be necessary to add a corticosteroid, particularly if their eosinophil counts are above 100 cells/mL.

In patients with severe exacerbations, physicians can consider adding other agents, she said. GOLD recommends prescribing a short course (no more than five days) of systemic corticosteroids to improve lung function and oxygenation.

That said, patients with severe, persistent symptoms, evidenced by a history of hospital admissions, exacerbations, and significant limitations on activity, should be referred to a pulmonologist, said Dr. Martinez.

"Medication regimens become more complex in these patients and series of nonpharmacological interventions may be needed, including surgery," he said.

Troubleshooting

Before escalating existing medications, it's important to consider the impact of comorbid diseases, GOLD notes. COPD patients often have multiple diseases and a high burden of prescription medications, underscoring the importance of simplifying treatment.

"The majority of COPD patients are current or former smokers, so there is a lot of comorbid cardiac disease and a higher risk for lung cancer," said Dr. Wilgus. "If a patient has uncontrolled symptoms, it's important to take a step back and consider that another problem may be clouding the picture and contributing to respiratory symptoms."

Depression/anxiety and osteoporosis are also seen frequently and are often underdiagnosed and associated with poor health status and prognoses in COPD, the GOLD report states. Symptoms may be overlooked because they are similar to those associated with COPD, such as breathlessness related to heart failure and lung cancer, or fatigue and reduced activity tied to depression. Patients are more likely to develop depression following a COPD diagnosis, and COPD patients are almost two times more likely to die by suicide than those without the disease, according to GOLD.

Cognitive impairment and frailty are also common in COPD, underscoring the importance of tailoring delivery systems to individual patients, said Dr. Hanania. For example, metered-dose and dry-powder inhalers can present difficulties for some patients.

"Metered-dose inhalers require nine steps to use them correctly, which is problematic for a patient with physical dexterity or cognitive issues," he said. "Similarly, some very frail older patients can't generate enough air flow to use a dry-powder inhaler or they don't like the feel of the powder in their mouth."

It's necessary to take a personalized approach to managing COPD, he added. There is no one-size-fits-all regimen due to the variety of factors that affect outcomes.

"As a physician, I have to decide which medication and delivery system is right for each patient," he said. "Those should be shared decisions that consider the patient's abilities and preferences as well as access and cost."