COPD: An Individualized Approach to Medication and Delivery - Episode 2
Peter Salgo, MD: First of all, I admire all of you, because this is a moving target. Chronic obstructive pulmonary disease (COPD) doesn’t just stay there, it changes. It morphs. It’s associated with all of these other comorbidities. It’s associated with heart disease, osteoporosis, a lot of respiratory infections, and with depression. How much of this is due to the COPD? How many people with COPD get these things because they are who they are? How do you begin to tease that out?
Antonio Anzueto, MD: We need to look at the individual, not look at the disease.
Peter Salgo, MD: That is the most profound thing I’ve heard in a very long time. You look at the individual, not the disease. This isn’t a textbook.
Antonio Anzueto, MD: The point is, it’s not that they have COPD or diabetes or heart disease. Those 3 conditions were produced by cigarette smoking. In your chart, your patient has 2 of the prior ones, and they will have COPD. You have not looked for it. You have not done the spirometry to make a diagnosis. Now, we understand that it’s not that an individual has a disease as a consequence of cigarette smoking. He or she has coronary artery disease, high blood pressure, COPD, osteoporosis, depression. We have to look at all of those conditions together.
Peter Salgo, MD: Byron?
Byron Thomashow, MD: I completely agree with what Antonio said. You need to treat the person with COPD, not the COPD. The foundation did a survey with about 3000 patients a number of years ago, and 50% of them had 6 to 10 comorbid conditions. Another 20% had over 11. You can only envision how many medicines those people would walk away with by being prescribed with medications for the different processes. You need to treat the person, and that’s not a simple thing to do.
Peter Salgo, MD: I’m not sure that we have data on this. If you’re going to look at a person with COPD, and they have 10 medications, do we have a control group that is age corrected? How many medicines is somebody without COPD on at the same age? Do we know?
Barbara P. Yawn, MD, MSc, FAAFP: There are some data that suggest that after age 65, the average person has 3 or 4 issues. Then, you get up to age 70. That number goes up. You get up to age 80, and we’re talking about 7 to 8 to 10 conditions. It is fewer medications for someone who does not have COPD, and this is mainly someone who has not been a long-term smoker.
I also want to point out that about 20% of people do not have personal smoking as their risk factor for COPD. We can’t forget about those very important people. You can’t only say, “Well, you’re a long-term smoker. You probably have COPD.” There are others that have the symptoms—all of the signs. You have to think about COPD in those people. Maybe they were around other smokers. Maybe they’re in an occupation where they are exposed to a lot of inhalation triggers. So, please don’t forget those people. If it looks like COPD, go ahead and evaluate it.
Byron Thomashow, MD: We know very little about how COPD actually behaves in the nonsmoking population. If there are, for argument’s sake, 30 million people in this country with COPD, and 20% or 25% of them never actually smoked, that’s a lot of people. And yet, almost every study that has ever been done in COPD has eliminated people who never smoked. It’s a huge area, and we don’t know much about it.
Antonio Anzueto, MD: Worldwide, biomass exposure is the number 1 cause of COPD.
Peter Salgo, MD: Worldwide?
Antonio Anzueto, MD: Yes. I grew up in a rural area, where mothers cooked with woodstoves. They were exposed to that for 8 to 10 years. They never smoked. Now they’re in their 50s, and they have obstruction. So, like Barbara said, we need to remember other causes of this condition.
Peter Salgo, MD: You were going to say something?
James F. Donohue, MD: I was a visiting professor in India last week. Half of the COPD there is caused by biomass, similarly, as Antonio was saying. In South America and Mexico, women get it. There have been a lot of studies about the phenotype of COPD in that nonsmoking population. One of the problems, in some of the societies, is that the women are not tall. They’re probably a little more vulnerable to COPD, in the sense of the lung growth and size. The natural history of that, when the exposure is removed, is being studied.
The common factors in all of these comorbid conditions are inflammation from cigarette smoking and people who are worried about dental plaque causing coronary artery disease. When you have an entire lung, a massive organ, full of inflammation, you can imagine the effects of that. Not only in practice, but also in clinical trials like the TORCH study, we power mortality studies on all-cause mortality. In the COPD patients, one-third will die of heart disease. Another third will die of lung cancer. And then, a third, maybe those who are a little bit older, will die of the COPD.
Peter Salgo, MD: That’s what I was getting at earlier.
James F. Donohue, MD: Yes. So, it’s really important to look at the patients in the setting of their comorbidities. I still practice every day—as we all do on the panel, here—and the biggest problem is, again, the multiple medicines and the lack of affordability in the doughnut hole.
Peter Salgo, MD: We’re going to get to that.
James F. Donohue, MD: I know that we’re going to get to it later, and that is an extremely important concept. From the studies that I just mentioned, like TORCH, we know that one of the most important causes of poor survival is nonadherence. That’s often a factor.
Antonio Anzueto, MD: Let me bring another important issue in—comorbidities. A group in Spain has looked at exacerbations and why patients won’t come back. They have a nursing staff. They go to the house. They do everything that they are supposed to do, and patients keep coming back. What they started doing is examining patients’ mouths. People who had more dental disease are the people who have more exacerbations and more problems. That’s something that we don’t do. I’m the only one in the clinic that uses tongue depressors. Nobody uses tongue depressors. I look in everybody’s mouth.
Peter Salgo, MD: I don’t know if that’s a marker or if there’s an ideologic relationship, but it’s fascinating.
Antonio Anzueto, MD: You have to look in their mouth. With this dental disease, you have to have them go to the dentist. So, I go back to my initial statement—we need to look at the individual.
Transcript edited for clarity.