Review offers guidance on selecting medications for COPD

Physicians often prioritize selection of an inhaled medication over the delivery system when prescribing pharmacotherapy for patients with chronic obstructive pulmonary disease (COPD), but treatment decisions should include assessment of cognitive function, manual dexterity/strength, and peak inspiratory flow (PIF), according to a recent article.

Researchers reviewed available guidance and evidence to examine the prevalence of impairments in these three areas in patients with COPD, to describe how they affect ability to use an inhaler, and to provide information on tests to assess these factors in individual patients. Their findings were published Nov. 15 by CHEST.

Clinicians should ask patients with COPD and their family members/caregivers if they have noticed any problems with memory or ability to understand or follow instructions, as well as any declines in cognitive ability over time. Treatable factors that can impair cognition, including thyroid disease and medication side effects, should be excluded during the history and physical, the authors noted. The 2023 GOLD report recommends that clinicians assess patients' inhaler technique at every appointment, which can include asking patients to describe or demonstrate use, the authors said.

“Although testing cognitive function is not routinely performed when prescribing an inhaled medication delivery system, HCPs [health care professionals] should consider screening tests for cognitive impairment in selected individuals if there are any findings suggesting a problem with memory and/or ability to follow instructions,” they wrote. They noted that the Mini Mental State Exam and the Montreal Cognitive Assessment are appropriate for this purpose.

No studies have reported the prevalence of impairment in manual dexterity or strength in patients with COPD, the authors said, but 79% of patients with COPD in one study reported at least one physical impediment that could affect their ability to use an inhaler device. If assessment of inhaler technique indicates that the patient may have limited manual dexterity and strength, the clinician can consider using the Functional Dexterity Test, as well as measuring hand grip strength using a dynamometer.

Measuring PIF against the simulated resistance (r) of a dry powder inhaler (DPI) can indicate whether the patient has enough inhalation ability to correctly use the device, the authors noted. Studies have indicated that PIFr should be measured directly and that maximal forced inspiratory flow as measured by a spirometer is not an adequate proxy. “We encourage HCPs to measure PIFr when considering prescribing a DPI for two reasons: the measurement establishes whether the patient has the inhalation ability for creating optimal turbulent energy within the DPI; and actual performance of the PIFr maneuver provides feed back to the patient on the optimal inspiratory effort required to use the device,” the authors wrote. They also stressed that shared decision making is vital in choosing an inhaler device and that patient preference should be taken into account.

“As patients with COPD make frequent errors when using handheld devices and may also be poorly adherent, it is important that [clinicians] match the specific features of the different delivery systems with the abilities of the individual patient with COPD to achieve clinical benefits,” the authors wrote. “For some, or even many, patients with COPD, any of the four inhaled delivery systems will likely provide clinical benefits if the device is used correctly in an adherent manner.”