What are the diagnosis and treatment options for Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Chronic Obstructive Pulmonary Disease (COPD) diagnosis and treatment should prioritize a comprehensive approach, including diagnosis confirmation with postbronchodilator spirometry, and management with evidence-informed nonpharmacological and pharmacological interventions, as outlined in the 2023 Canadian Thoracic Society guideline 1.

Diagnosis

COPD diagnosis requires spirometry showing a post-bronchodilator FEV1/FVC ratio less than 0.7, confirming airflow limitation, as supported by the 2023 Canadian Thoracic Society guideline 1 and the 2018 GOLD report 1. The diagnosis should also consider clinical evaluation, routine follow-up, and assessment of symptoms and risk factors.

Treatment

Treatment follows a stepwise approach based on symptom severity and exacerbation risk. For most patients, treatment begins with a short-acting bronchodilator like albuterol (2 puffs every 4-6 hours as needed) for symptom relief. As symptoms persist, long-acting bronchodilators become the cornerstone of maintenance therapy, including long-acting beta-agonists (LABAs) like salmeterol or formoterol, and long-acting muscarinic antagonists (LAMAs) like tiotropium (18mcg daily). Some key points to consider in treatment include:

• Combination therapy with LABA+LAMA or adding inhaled corticosteroids (ICS) like fluticasone is recommended for patients with frequent exacerbations or severe symptoms.
• Pulmonary rehabilitation, smoking cessation, and annual influenza vaccination are essential non-pharmacological interventions.
• Oxygen therapy is indicated for patients with severe hypoxemia (PaO2 ≤55 mmHg or SaO2 ≤88%).
• During acute exacerbations, treatment includes increased bronchodilator use, oral corticosteroids (prednisone 40mg daily for 5 days), and antibiotics if bacterial infection is suspected.

Management Goals

The primary goals of COPD management are to improve lung function, reduce dyspnea and other symptoms, enhance health status, and reduce acute exacerbations of COPD (AECOPD), which are strongly associated with increased mortality, as emphasized in the 2023 Canadian Thoracic Society guideline 1.

Non-Pharmacological Interventions

Non-pharmacological interventions, such as pulmonary rehabilitation and smoking cessation, play a crucial role in COPD management, as highlighted in the 2023 Canadian Thoracic Society guideline 1 and the 2018 GOLD report 1. These interventions can significantly improve quality of life and reduce symptoms in patients with COPD.

Pharmacological Interventions

Pharmacological interventions, including bronchodilators and inhaled corticosteroids, are essential in managing COPD symptoms and reducing exacerbations, as supported by the 2023 Canadian Thoracic Society guideline 1 and the 2011 clinical practice guideline from the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society 1.

Quality of Life and Mortality

The ultimate goal of COPD management is to improve quality of life and reduce mortality, as emphasized in the 2023 Canadian Thoracic Society guideline 1. By prioritizing a comprehensive approach to diagnosis and treatment, healthcare providers can help patients with COPD achieve better outcomes and improve their overall quality of life.

From the FDA Drug Label

The efficacy of STIOLTO RESPIMAT is based primarily on two 4-week dose-ranging trials in 592 COPD patients and two confirmatory active-controlled 52-week trials (Trials 1 and 2) in 5,162 COPD patients. STIOLTO RESPIMAT is a combination of tiotropium bromide and olodaterol indicated for long-term, once-daily maintenance treatment of patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema STIOLTO RESPIMAT is not indicated to treat acute deteriorations of COPD [see Warnings and Precautions (5.2)].

COPD Diagnosis and Treatment:

• The diagnosis of COPD is based on a clinical diagnosis, a smoking history of more than 10 pack-years, and moderate to very severe pulmonary impairment (post-bronchodilator FEV1 less than 80% predicted normal [GOLD Stage 2-4]; post-bronchodilator FEV1 to FVC ratio of less than 70%) 2.
• The treatment of COPD with STIOLTO RESPIMAT is indicated for long-term, once-daily maintenance treatment of patients with COPD, including chronic bronchitis and/or emphysema 2.
• Key Points:
  • STIOLTO RESPIMAT is not indicated to treat acute deteriorations of COPD.
  • STIOLTO RESPIMAT is not indicated for the treatment of asthma.
  • The recommended dosage of STIOLTO RESPIMAT is two inhalations once-daily at the same time of the day 2.

From the Research

COPD Diagnosis

• The diagnosis of COPD should be suspected in patients with risk factors, such as a history of smoking, who report dyspnea at rest or with exertion, chronic cough with or without sputum production, or a history of wheezing 3.
• Spirometry is the reference standard for diagnosing and assessing the severity of COPD, and all patients should undergo spirometry to confirm airflow obstruction 4, 3.
• Findings that are most helpful to rule in COPD include a smoking history of more than 40 pack-years, a self-reported history of COPD, maximal laryngeal height, and age older than 45 years 3.

COPD Treatment

• Treatment should be guided by the severity of lung impairment, symptoms such as dyspnea, the amount of cough and sputum production, and how often a patient experiences an exacerbation 4.
• Once- or twice-daily maintenance long-acting anticholinergic and β-agonist bronchodilators should be used to treat COPD when dyspnea limits activity or quality of life 4.
• Patients with acute exacerbations may benefit from the addition of inhaled corticosteroids, particularly those with elevated peripheral eosinophil levels 4.
• Tiotropium, a long-acting muscarinic antagonist (LAMA), is safe and efficacious as a long-term, once-daily treatment for the maintenance treatment of COPD and for reducing COPD exacerbations 5, 6.

COPD Management

• Pulmonary rehabilitation, which includes strength and endurance training and educational, nutritional, and psychosocial support, improves symptoms and exercise tolerance but is underutilized 4.
• Supplemental oxygen for patients with resting hypoxemia (defined as Spo2 <89%) improves survival 4.
• Current guidelines recommend starting monotherapy with an inhaled bronchodilator, stepping up to combination therapy as needed, and/or adding inhaled corticosteroids as symptom severity and airflow obstruction progress 3.

Barriers to COPD Diagnosis and Treatment

• Primary care physicians may not prioritize COPD diagnosis and treatment due to skepticism about the utility of spirometry and the lack of evidence that medication leads to improved outcomes 7.
• Health system barriers specific to spirometry use were not identified, suggesting that increasing the use of spirometry among primary care physicians requires changing their beliefs about its utility in COPD diagnosis 7.