Expanding Treatment Options: The Latest Developments in COPD - Episode 3

Challenges Associated with Medication Delivery Devices in COPD

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The MD Magazine Peer Exchange “Expanding Treatment Options: The Latest Developments in COPD Therapy” features a panel of physician experts discussing key topics in COPD therapy, including risk factors, personalized treatment, preventive measures, new combination therapies, and more.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

  • Byron Thomashow, MD, professor of medicine at Columbia University Medical Center, medical director at the Jo-Ann LeBuhn Center for Chest Disease at New York-Presbyterian Hospital, and chairman of the board of the COPD Foundation
  • Neil R. MacIntyre, MD, clinical chief of the Pulmonary/Critical Care Division, medical director of Respiratory Care Services, and professor of medicine at Duke University School of Medicine
  • Barry J. Make, MD, director of Pulmonary and Respiratory Care for National Jewish Health and professor of medicine at the University of Colorado School of Medicine
  • Nicola A. Hanania, MD, MS, associate professor of medicine and director of the Asthma and COPD Clinical Research Center at Baylor College of Medicine

Clinicians can prescribe medications to treat COPD but if patients do not understand how and when to use them “it will be a waste of their money and a waste of our time and we don’t get any outcomes,” said Dr. Hanania. “We have to assess the severity of the disease, how short of breath they are to decide which treatment to choose. But we also have to keep in mind the patient and maybe the caregiver, too. Sometimes the patients are cognitively dysfunctional, so we have to really address the issues with the caregiver of these patients.”

Dr. Thomashow agreed that taking the time to explain and demonstrate how to properly use inhalers and other devices is important. He also noted that the decision of which drug/device is the best fit for a particular patient is often out of the physician’s hands. Insurance companies often take the view that all members of a particular drug class are the same, even though there may be important clinical differences between the medications.

“So a person can be on one medication that you’ve prescribed and showed them how to use the device, and lo and behold, the insurance company says, ‘no, he has to be another device and he has to fail that medicine, that device before we’ll allow him to even consider using the medicine that you’ve prescribed.’ That’s an issue that didn’t exist in the past,” he said.

Comorbidities should also factor heavily in medication selection. For example, physicians should be cautious about prescribing bronchodilators for patients with cardiovascular comorbidities, especially those with severe heart disease, said Dr. Hanania. “And we can’t really prescribe anticholinergics for patients with severe prostate disease with urinary outlet obstruction. So we have to keep the comorbidities in mind when making decisions about which medications are appropriate.”

Dr. MacIntyre said that even something as ubiquitous as giving a patient an aerosol is fraught with challenges and the potential for less than optimal outcomes. This is because “getting an aerosol into the lung is one of the most challenging things before us,” he said.

The respiratory system has a host of “defenses to prevent dust, fumes, aerosols, and all the other stuff we breathe in the air from getting into the lung and we have to overcome that. We have to get that 90-degree angle. We’ve got to get through the vocal cords. We’ve got to go out through 23 branches of the tracheal bronchial tree and hopefully get these medicines to go where we want. It requires a careful breathing maneuver that many of these patients can’t do very well. It requires a breath hold, which many of them find very difficult to do. It requires coordination, which many older patients have great difficulty with… The disease gets in the way. The narrower your airway; the more difficulty you’re going to have getting aerosols into the regions you want them to go.”