COPD: An Individualized Approach to Medication and Delivery - Episode 7
Peter Salgo, MD: Let’s talk a little bit about these treatment decisions. What have we got? We’ve got the short-acting bronchodilators (SABAs), the long-acting bronchodilators (LABAs), the long-acting muscarinic antagonists (LAMAs), and inhaled corticosteroids (ICSs). How do you make decisions about these things? What do you use, and in whom?
James F. Donohue, MD: This is very, very complicated, because we do have a lot of choices. A lot of them are “me-toos.” The 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines really have made it very nice and simple. I think everybody needs a short-acting rescue medicine like albuterol or ipratropium. Or, you could use the 2, together.
Peter Salgo, MD: That’s a SABA?
James F. Donohue, MD: That’s a SAMA [short-acting muscarinic antagonist], or a SABA, or even in combination. In asthma, if it’s the only thing that you have, you can pretreat yourself before you walk, and you could get something out of it. Most people start with a long-acting bronchodilator—a 12-hour or 24-hour bronchodilator. That could either be an anti-muscarinic agent, or a long-acting beta agonist, or—what I really like to use, to make life really simple—both, as the first drug. What everyone has used for years are inhaled steroids and long-acting beta agonists because that’s simple. That’s a really good asthma therapy, first-line. Then, all of these patients are wheezing.
Barbara P. Yawn, MD, MSc, FAAFP: Don’t do first-line there, either.
James F. Donohue, MD: Yes, anyway…
Barbara P. Yawn, MD, MSc, FAAFP: The ICSs.
James F. Donohue, MD: Yes, but that revolutionized the lives of our patients with asthma and chronic obstructive pulmonary disease—the ICSs in the first-line setting. You’re right, Barbara. But, anyway, we think about the one-size-fits-all approach. That’s what I was saying. It’s a simple story. It’s simple marketing. Use Advair or Symbicort.
Peter Salgo, MD: Her blood pressure’s gone to 280/150. What just happened here?
Barbara P. Yawn, MD, MSc, FAAFP: As you pointed out, it’s a real problem. It is not a one-size-fits-all approach. And when you look at therapy for COPD, it is frequently this combination of a long-acting bronchodilator and ICS. That is not the appropriate first therapy.
James F. Donohue, MD: I completely agree.
Peter Salgo, MD: What is the appropriate first therapy?
Barbara P. Yawn, MD, MSc, FAAFP: I like to think of this as a hierarchy. There is the short-acting bronchodilator. Then, you add a long-acting, or, both classes of the long-acting bronchodilator. And then, there are indications for going on, to add other medications. It is not automatic. Then, you just add ICS, if they’re still not doing well.
Peter Salgo, MD: Now, one of the things that Byron taught me was that if you give a long-acting bronchodilator or a muscarinic drug, you could actually shrink lung volumes, over time. This is, if you will, and forgive me for the oversimplification, a chemical lung volume reduction. That improves function. So, where does that fit, here? Are they saying that? Is that what you’re hearing?
Byron Thomashow, MD: Yes.
James F. Donohue, MD: OK. So, the 2 bronchodilators—the LABA/LAMA combination, which I happen to like a lot. The most important thing is that the shortness of breath is driven by the air trapping—the hyperinflation. That’s why I like it. If they don’t respond to one, the other one is there. There’s no escalation in adverse effects when you put the 2 together. So, anyway, that’s a nice combination. Now, what about the inhaled steroid/LABA? That’s another very nice combination. Or, even as triple therapy. GOLD gives us nice guidelines. There’s an asthma/COPD overlap. We see people with a lot of eosinophils as markers of allergic inflammation—300 cells per cubic millimeter. Those are people with severe disease and, most importantly, people who have a lot of exacerbations. They are the frequent flyers. They need that steroid. So, to make it pretty simple—monotherapy with a long-acting agent and, maybe, dual bronchodilators. And then, either add a triple or just ICS/LABA.
Antonio Anzueto, MD: I think that the message, here, is that COPD is a treatable disease. It can be treated. These bronchodilators have changed the natural history. They have improved lung function and quality of life. So, the foundation is long-acting bronchodilators. Most of the time, I’m now using the fixed combination, because you give 2 different mechanisms for the price of 1.
Byron Thomashow, MD: And, there’s no increase in adverse effects.
Barbara P. Yawn, MD, MSc, FAAFP: That’s a really important message that I don’t think primary care hears all the time. You’re using 2 long-acting bronchodilators, but they are different mechanisms of action. So, yes, you use them together and they’re synergistic.
Transcript edited for clarity.