Therapeutic Strategies in the Management of COPD - Episode 7
Peter L. Salgo, MD: In the office, if you’re a primary care physician, how do you assess the severity of this disease? What are the good questions?
Frank C. Sciurba, MD, FCCP: One of our colleagues actually wrote a wonderful manuscript. We have these 12-item patient questionnaires. We have these 24-item questionnaires. Our colleague, however, said that all you need are 2 questions: “How are you doing,” and, “What are you doing?” And you say, “I’m doing fine.” “What are you doing?” “Nothing, I’m sitting on the couch. I’m barely able to make breakfast anymore, but I’ve got people doing that for me.”
And so, those are probably the 2 key questions to address that there’s issues in the beginning. “What happens when you do a little bit more?” “Well, I just don’t feel like it.” “But what happens?” “Well, maybe I get a little more shortness of breath, but I’m just getting old and I smoke.” But those are the questions.
Byron Thomashow, MD: The other thing that I think is important to stress is, and it certainly comes up with the comorbidity issue, you can’t take care of COPD by just taking care of the COPD. This is why primary care is such a critical issue. You have to take care of the person who has the COPD. Almost all of them have various other medical issues. In some sense, patients, themselves, may view COPD as simpler to manage. They don’t have to take the medicine if they just don’t do anything. That’s not the approach. People have to do things.
Peter L. Salgo, MD: If I understand you correctly, you have to talk to people?
Byron Thomashow, MD: You have to talk to the people. You need to know what you have. You mentioned, earlier on, the fact that it is a leading cause of readmissions. But for whatever the index cause of that first hospitalization is, what’s clear is that most readmissions are about comorbid conditions. That’s clearly true in the COPD world.
Peter L. Salgo, MD: Let’s move on and discuss the pharmacologic approaches for a bit. You were talking about LABAs (long-acting beta-agonists) and LAMAs (long-acting muscarinics). Which patients need both LABAs and LAMAs?
Frank C. Sciurba, MD, FCCP: There’s a bit of a philosophical difference here. The GOLD criteria say even with patients who are very symptomatic with advanced disease, you start 1 bronchodilator. And then, if it doesn’t resolve things, you progress. But in my experience, after seeing several thousand patients with COPD, it’s never fully reversible. I’ve never had a patient in whom I have completely gotten rid of their symptoms or activity intolerance. I’m inclined, except in mild disease, to start with a double bronchodilator, early on, often not with the inhaled steroid, unless they have this asthma overlap or they really are already frequent exacerbators who have not been treated. I do tend to start with the LAMA/LABA combination in patients with moderate to severe disease. Fernando is on this GOLD committee. Maybe he can give us some insight on the discussion?
Fernando J. Martinez, MD: No, that fits within the GOLD components as well. Jim?
James F. Donohue, MD: I very strongly support what Frank says. When I was chief, I put clinics out into the community, in a small town, a rural area, with a much less sophisticated population. At the university, when those patients come and they are short of breath, they want relief. They don’t want me to screw around with clinical trials of 30 or 90 days. Having spent most of the last 20 years of my life studying the LABA/LAMAs and the combinations, we know that there are responder rates. Some people do great with a LAMA, and some don’t. Some do great with a LABA, and some don’t. When you put them together, everybody responds at least a little bit. So, I give them both.
Peter L. Salgo, MD: What combinations are out there, in terms of fixed-dose options for both LABAs and LAMAs?
James F. Donohue, MD: Well, you have umeclidinium and vilanterol. That’s called Anoro Ellipta. It’s a dry powder inhaler. We might want to talk about dry powders, also. Then, you have a soft mist inhaler, Stiolto Respimat, with tiotropium and olodaterol. Then, you have Ultibro, which is indacaterol and glycopyrronium. Another very new option, which I like a little bit because it’s still a metered-dose inhaler, is called Bevespi. That’s formoterol and glycopyrrolate. And then, another one is coming, Tudorza, which is aclidinium plus formoterol. So, you have all of these different things. It’s going to be based on cost. They’re all very similar. When we do the dose response, we can’t give you a bottom line. They all have to be similarly anchored to other existing therapies, so there’s no way that one is a real breakthrough. They’re all more similar than dissimilar.
Peter L. Salgo, MD: So, the advantages of fixed-dose combination therapy are?
James F. Donohue, MD: It’s a small advantage on compliance. I discussed that with the FDA. The numbers, with a once-a-day drug in COPD, are 47% versus 39%, or something like that. So, it’s within 10 points.
Peter L. Salgo, MD: That’s real.
James F. Donohue, MD: It’s real. You wish everybody was at 60%, or 70%, or 80%, of course, but there is a compliance advantage. We know that compliance, and that’s what the argument is for, with the generic drugs, enhances compliance and reduces exacerbations.
Byron Thomashow, MD: Now, there are 2 points I think that Jim mentioned that are worth stressing. Being old, I remember when blood pressure medicines were 4-times a day. When you went from 4-times a day to twice a day, it was life-changing. Going from 2 to 1? That’s not so clear. GOLD, among other things, deserves the credit. For the longest time, you asked who got treated. It depended upon their FEV1 (forced expiratory volume in 1 second) level. And GOLD recognized, as many of us now have, that it’s really about symptoms and exacerbations. And the neat thing, as Jim mentioned, is that the LAMA/LABAs not only seem to improve symptoms, but they do a pretty good job in controlling exacerbations as well.
Transcript edited for clarity.