What are the recommendations for a patient with chronic obstructive pulmonary disease (COPD) and polycythemia, who is a heavy smoker and refuses to quit, with a recent complete blood count (CBC) showing elevated hemoglobin, hematocrit, and red blood cell (RBC) count, and is being considered for escalation of treatment to Trelegy (fluticasone furoate/umeclidinium/vilanterol)?

Management of COPD with Polycythemia in a Heavy Smoker Declining Cessation

For a COPD patient with polycythemia (Hgb 17.4, Hct 50.7, RBC 5.4) who refuses smoking cessation, escalation to Trelegy (fluticasone furoate/umeclidinium/vilanterol) is appropriate, but smoking cessation should continue to be strongly encouraged at every visit as it remains the most effective intervention to reduce mortality.

Primary Management Approach

Addressing Smoking Status

• Smoking cessation remains the single most effective intervention to slow FEV1 decline and improve outcomes in COPD 1
• Despite patient refusal, brief smoking cessation advice should be provided at every clinical encounter
• Consider offering nicotine replacement therapy (patches, gum) even if previous attempts have failed 1
• Document smoking status and continued advice in medical record

Polycythemia Management

• The elevated hemoglobin, hematocrit and RBC count indicate secondary polycythemia, likely due to chronic hypoxemia
• Smoking directly contributes to polycythemia in COPD patients through carboxyhemoglobin formation 2
• Polycythemia will likely persist or worsen if smoking continues, even with oxygen therapy 2
• Consider evaluation for oxygen therapy if patient meets criteria:
  • PaO2 ≤ 55 mmHg or SaO2 ≤ 88% 1
  • PaO2 between 55-60 mmHg with evidence of polycythemia (as in this case) 1

Pharmacologic Treatment

Triple Therapy with Trelegy

• Trelegy (fluticasone furoate/umeclidinium/vilanterol) is appropriate for patients with severe COPD and high risk of exacerbations 1
• Contains three components:
  • Fluticasone furoate (inhaled corticosteroid)
  • Umeclidinium (long-acting muscarinic antagonist/LAMA)
  • Vilanterol (long-acting beta-agonist/LABA)
• Recommended dosage: 1 actuation once daily by oral inhalation 3
• Patient should rinse mouth after use to reduce risk of oral candidiasis 3

Additional Management Considerations

Monitoring and Follow-up

• Regular monitoring of symptoms, exacerbations, and airflow limitation is essential 1
• Check inhaler technique at each visit
• Monitor hemoglobin/hematocrit levels to assess progression of polycythemia
• Evaluate for worsening hypoxemia that may require oxygen therapy

Preventive Measures

• Annual influenza vaccination is strongly recommended 1
• Pneumococcal vaccination (both PCV13 and PPSV23) for patients over 65 years 1
• Encourage physical activity within limitations of disease 1

Potential Pitfalls and Caveats

1. Polycythemia management: Smoking cessation is critical for managing polycythemia in COPD. Long-term oxygen therapy may not effectively reduce polycythemia if the patient continues to smoke 2

2. Beta-blockers: Avoid beta-blockers (including eye drops) as they can worsen bronchospasm in COPD patients 1

3. Inhaler technique: Up to 76% of COPD patients make important errors when using inhalers. Technique should be demonstrated and checked regularly 1

4. Oxygen assessment: Despite polycythemia, formal assessment for oxygen therapy should be performed before prescribing, as inappropriate oxygen use carries risks

5. Monitoring for side effects: Monitor for potential side effects of triple therapy, including pneumonia risk with inhaled corticosteroids

By addressing both the COPD and polycythemia while continuing to emphasize smoking cessation, this approach provides the best chance for improving the patient's morbidity, mortality, and quality of life.