Medical Post COPD Interview
By Dr. Shafiq Qaadri, MD
What is COPD?
COPD is really several diseases—the common element is reduced airflow. It means you have low lung function, trouble bringing air in and out.
It can consist of emphysema, with the typical enlarged airspaces; there are other types of COPD, more like chronic bronchitis, which result in a productive cough.
Is smoking the only cause?
It’s the most prominent cause in most Western countries, accounting for 80 to 90% of all COPD, but it’s not the only cause.
You can get COPD from other things, such as occupational exposure and indoor pollution. For example, in developing countries, they often burn fuels inside houses, and this can lead to quite severe COPD.
Is COPD on the increase?
Yes, it’s definitely on the increase—that’s the frightening thing. Other major diseases, like cardiovascular disease or cerebrovascular disease, are decreasing, but COPD is on the rise.
It’s the result of the cumulative effect of many years of smoking. And even if you stop smoking, you can still have COPD, and it can continue to worsen with age.
We also have a very alarming increase among women, who, as a group, took up smoking after World War II.
Does the European experience with COPD differ significantly with the North American experience?
No, not in general terms. Sometimes it’s a question of terminology. In the US, for example, the term emphysema is used more often than in Europe.
But we see the same trends: in men, the increase is slowing, but in women it’s increasing rapidly. In lower age ranges particularly, women are overtaking men.
Is COPD a significant burden for healthcare utilization?
Yes, it’s very important, but also somewhat invisible. For example, many patients with mild to moderate COPD will have exacerbations, which require treatment and cause time off work. But they remain undiagnosed, and just think they have a prolonged cold or yet another flu. Their condition is typically not recognized to be COPD until fairly late.
Is there a significant mortality associated with COPD?
The MORBIDITY is actually the worst part. Generally, it’s a disease you can have for decades, and can often be associated with other co-morbid disorders.
If you look at hospitalizations, days spent in hospital, you get a better picture of the burden.
What are some of the patient barriers to the treatment and management of COPD?
The most important part is under-diagnosis. Looking at the National Health and Nutrition Examination Survey (NHANES) from the US, at least 2/3 of all COPD patients have not been given the diagnosis.
The next aspect is that patients feel that it’s a self-inflicted disease, so they feel guilty and blameworthy, and sometimes avoid seeking help.
Finally, I think there has been a very nihilistic approach to COPD: the thinking has been that maybe we can relieve breathlessness a little, but that there are no effective therapies for the underlying disease. We need to change that mindset rapidly.
How are doctors doing in their current management of COPD?
It depends how you look at it—half full or half empty. Many patients are doing well. If we look at the Confronting COPD in Canada Survey, patients had a lot of positive things to say about their doctors: that their doctors understood their disease, and took an active management role.
But generally we are underestimating how sick the patients are. It’s partly due to the fact that patients seem to adjust their set point of what they expect. So even though they may have severe restrictions in their activities of daily living, they still describe their disease as mild or moderate.
What are the treatment trends and research revealing about the management of COPD?
One of the main changes is that we are not just using short-acting bronchodilators to control symptoms. We have growing evidence that long-acting bronchodilators and the inhaled corticosteroids benefit these patients.
The way these medications can help is by relieving symptoms, particularly dyspnea—breathlessness—which is the key symptom in COPD. They can also reduce the number of exacerbations, which disturb the quality of life.
Why use combination therapy?
We have good clinical trials which show that combination therapy works better than the individual drugs alone. It’s also a practical option for patients, and aids compliance. They experience fewer medications, yet get the effect of several drugs.
Is their clinical and biological evidence for the synergy of these agents?
It’s an intense area of research and discussion, whether the drugs together are more effective in one inhaler than separately in two inhalers.
So far, most of our experience comes from asthma, where there is synergy, both from a theoretical point of view and in clinical practice. We still need more studies in COPD to be sure that the same mechanisms are operative.
Do you actively advocate smoking cessation, or is it an uphill battle?
It’s a battle, but not necessarily uphill. I think doctors have this notion that COPD patients never give up smoking. But we still believe intense efforts for smoking cessation are critical for the care of these patients.
If patients use combination therapy, can they expect that their lung function and pathology will be stabilized?
We don’t have the full answer to that. Patients can generally increase their lung function with these drugs, returning to the lung status they had five years earlier. It does not mean we have reversed what is going on in their lungs, but we can definitely make them feel better.
Also, the fact that we can reduce the number of exacerbations tells us that we can probably arrest, to some extent, the further progression of the disease. But further studies are needed to clearly demonstrate that.
What are the recommended dosages for combination therapy?
Dosing is still a problem. Current evidence, for example, is on 50 micrograms of salmeterol with 500 micrograms of fluticasone, given twice daily. That’s the best documented dose.
Is it ever too late to quit smoking or too late to begin combination therapy?
No, it’s never too late to start therapy. Various studies have included much older patients than we would usually see, say, in hypertension trials. Whether it’s too late to stop smoking is debatable. From epidemiology, we know that the benefit of quitting smoking is less once your COPD is severe. The best course is to quit early to halt the progression of the disease.
What are the key points of the ISOLDE Trial?
This is one of the first long-term trials of inhaled corticosteroids and COPD. The thing that makes this study interesting is that it’s the first study that included sick patients, with poor lung function, with only 40% of predicted values. These are the type of patients that most pulmonary physicians treat in their practices.
The finding that the inhaled corticosteroids could reduce the number of COPD exacerbations, and prevent the very rapid decline in the health status and quality of life, was very notable.
What kind of improvement can COPD patients expect, in terms of FEV1 resolution or symptom control?
From the clinical trials so far, the combination therapies show that patients will start experiencing days where they will not have to take their reliever medications. They experience true relief of breathlessness.
Are the days of using anticholinergics alone for COPD over?
In mild COPD, there is still only a need for a short-acting bronchodilator such as the anticholinergics or salbutamol. But when patients become more ill, and start having exacerbations, then I think it’s not very proper to give bronchodilator therapy alone.
What is TORCH?
This is a global clinical trial to see if combination therapy can have an impact on COPD mortality. About 6000 patients have been entered into the study, and they are being randomized to have either placebo, the combination inhaler, or the inhalers separately. It will run for three years at least, so the data is pending.
What is your final message for physicians treating COPD?
The era of nihilism in COPD is gone. We should treat these patients aggressively with smoking cessation and rehabilitation. Also, we now have combination medications that can help these patients and, to some extent, the underlying disease process also.
Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education
(CME) lecturer. www.doctorQ.ca
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