CE
Pharmacists: 1.00 contact hour (0.1 CEUs)
Released: January 29, 2024
Expiration: January 28, 2025
Meet Judy, a 48-Year-Old Woman
As I transition into a conversation about managing COPD, I would like to introduce our first patient case. Judy is a 48-year-old woman who presents to the pulmonary clinic with mild dyspnea. She has a slight decrease in physical activity that is noticeable and a persistent cough that is sometimes productive.
Judy has been told that she might have COPD, and her primary care provider prescribed albuterol for her to use as needed via a metered-dose inhaler. In addition, Judy’s past medical history is significant for hypertension. She had childhood asthma and has overweight (with a BMI of 27.3 kg/m2). Judy has never smoked, lives with a nonsmoking partner, and has worked at a furniture manufacturing plant for approximately 25 years.
A prior chest x-ray was unremarkable, which helps rule out other causes of shortness of breath. Furthermore, Judy had an ECG revealing an ejection fraction of approximately 65%. Now, as you continue through this module, please consider whether you think Judy has COPD.
Evaluating Symptoms: mMRC Questionnaire
A few well-validated tools are available to evaluate patients’ symptoms of breathlessness, which can offer a more holistic symptom approach to diagnosing COPD. First, the modified Medical Research Council (mMRC) scale has been around for decades. This scale assesses only patients’ breathlessness. HCPs can simply ask a patient which description in the mMRC scale is most applicable to them. As an illustration, the scale ranges from “I only get breathless with strenuous exercise” to “I am too breathless to leave the house or I am breathless when dressing.”28,29
Evaluating Symptoms: mMRC Questionnaire
In practice, to streamline the use of this assessment tool, HCPs should first ask about grade 2: “I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level.” Then, adjust from there based on patients’ response.28,29
Evaluating Symptoms: CAT
Another tool for assessing patients’ symptoms is the COPD Assessment Test (CAT). CAT is another well-validated tool composed of 8 questions. It also correlates exceedingly well with the St. George’s Respiratory Questionnaire for COPD, which contains a plethora of questions. Just like the mMRC, HCPs should ask patients to rate their symptoms on a scale from 1-5. Total scores of less than 10 are uncommon in patients with COPD, and those greater than 10 are uncommon in healthy individuals.1,30
Judy, a 48-Year-Old Woman
Judy’s assessment resulted in an mMRC grade of 2 and a CAT score of 9, which is just below the cutoff of 10. Therefore, she may or may not have COPD.
In clinic, you would perform a spirometry, which in this case resulted in an FVC of 79% predicted, an FEV1 of 73% predicted, and an FEV1-to-FVC ratio of 0.75. This does not quite meet the diagnostic criterion for COPD, so you order and review a CT scan. The CT interpretation shows multiple focal areas of lobular air trapping consistent with small airway disease. You think to get a complete blood count with differential, and you have blood eosinophils at 114 cells/µL.
Remember, Judy has shortness of breath and a cough that is sometimes productive, but she has never smoked. You know that she works in an area that may not have good ventilation with fine particulate matter that is known to contribute to the development of COPD. It is important to note that there is enough information here—certainly considering a CT interpretation that is consistent with small airway disease—to make a COPD diagnosis, despite not meeting the spirometry cutoffs.
Given this additional information, does Judy have COPD? If she does in fact have COPD, how would you classify her COPD? Is it COPD-C, COPD-P, or COPD-A because of her asthma history?
GOLD 2024: Choosing Initial Therapy
Now, I will discuss how HCPs should choose the correct initial therapy for their patients. It is important to understand here that the GOLD report’s “ABE”-directed classifications should be applied (see slide). For patients who already are receiving maintenance therapy, their treatment also should be individualized. Then HCPs can escalate or de-escalate patients’ therapy based on their symptoms and exacerbations (or what the GOLD report refers to as a treatable trait). In addition, consider phenotypes vs looking back at patients’ ABE classification to ensure that they are receiving the right class of medication.
On the left side of the slide, you will see more information about classifying COPD using spirometry and/or an airflow assessment. For this module, I will focus on the right side of the slide, which directs therapy choice based on these assessments.
In the orange boxes on the left of the graphic, you will see group stratification based on patients’ exacerbation and hospitalization history. Then, using the orange boxes along the bottom, you can apply their mMRC and/or CAT results.
If Judy were diagnosed with COPD, you should note that she has had no exacerbations to our knowledge. Therefore, she would be in group A or B. Her CAT score would place her in group A, whereas her mMRC score would place her in group B. HCPs should use their discretion in selecting either a single or dual bronchodilator for Judy and engage with her in shared decision-making.1
Meet Billy, a 66-Year-Old Man
Moving on to our second patient case, Billy presents to your clinic after a recent hospital discharge for an acute COPD exacerbation. You find in the electronic health record (EHR) and after discussion with Billy that he has 1-2 exacerbations annually, with some requiring hospitalizations.
Billy’s past medical history is significant for COPD, with chronic bronchitis. He has heart failure with preserved ejection fraction, hypertension, and gastroesophageal reflux disorder. He has been receiving a LABA/LAMA fixed dose via a dry powder inhaler. In addition, Billy is a current smoker.
Per labs, Billy’s blood eosinophils were most recently 73 cells/µL. His FEV1 was 40% predicted, with that spirometry occurring within the past year. Today, his CAT score was 18, and his mMRC grade was 2. Please keep Billy in mind as I discuss how you can optimize his care.
Evaluating Patient Readiness to Quit Smoking
The best thing HCPs can do for patients with COPD who are current smokers is discuss the importance of smoking cessation. This affects patients’ lives more significantly than any pharmacologic intervention we can prescribe. A tool to guide you through these discussions—to help assess patients’ readiness to quit—is composed of the 5 A’s: ask, advise, assess, assist, and arrange.1
Of interest, the American Thoracic Society published recommendations in 2020 for prescribing varenicline to patients who are tobacco dependent, no matter their readiness to quit smoking.31
Immunizations in Stable COPD
Another important intervention to consider any time you are meeting with a patient with COPD is their immunization status. Immunizations are key in reducing or preventing illnesses that are more risky or prevalent in patients with COPD. The GOLD 2024 report recommends several vaccinations for those with COPD, including COVID-19, influenza, RSV (for those aged 60 years and older), and pneumococcal. These are important because viral infections could precipitate an exacerbation from which patients may not fully recover. In addition, the GOLD report recommends Tdap vaccination for those who did not receive it in adolescence, as well as zoster for those aged 50 years and older.1
COPD Management Best Practices
Some best practices for managing patients with COPD include initial medication selection, which is dictated by the GOLD report’s ABE classification. HCPs also must consider patients’ exacerbation history and symptom burden, which is dictated by their mMRC and/or CAT results. Once you have the appropriate medication class selected, you should consider device selection.1
Selecting the Most Appropriate Therapy
In selecting the appropriate therapy, again, consider if a patient is in group A, B, or E. For those in group A, bronchodilators, particularly LAMAs, are the cornerstone of therapy. Those in groups B and E should be prescribed LAMA/LABA combination therapy, which will result in improved FEV1 and quality of life. Combination therapy also reduces the number of exacerbations that patients experience.1,32
Also, remember that a small subset of patients (20%-40%) will have eosinophilic-driven exacerbations or inflammation. These patients could benefit from the use of an ICS.18
FDA-Approved Long-Acting Bronchodilator Therapies
There is a long list of FDA-approved long-acting bronchodilator therapies. On the slide, you can see that 4 LABAs and 5 LAMAs are available, as well as their respective brand names and delivery systems.
FDA-Approved Fixed-Dose Combination Therapies
A handful of fixed-dose combinations also are available. These are key in helping to consolidate the medications and devices that patients require after therapy escalation.
Considerations in Managing Pre-COPD/PRISm
It is important to remember that the most important loss of lung function occurs in patients with pre-COPD (those who are in the early stages of COPD) at their first exacerbation. Patients may not recover to baseline, and subsequent loss of lung function can have an exponential impact as each exacerbation occurs.33,34
In those with symptomatic COPD who qualify for triple therapy, risk of mortality is reduced.35 The RETHINC trial, in particular, highlights the need to explore novel treatment strategies for these patients.36 Therefore, it is critical that we improve efforts to recognize and diagnose these patients early in their disease trajectory. Consider the likelihood of COPD in patients with significant environmental exposures, the timing related to those exposures, and their genetics, even if spirometry does not indicate a COPD diagnosis per the GOLD report’s cutoffs.
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